MedPsych Integrated Referral Form 2025 Website

MedPsych Integrated Referral Form 2025 Website
Referring Provider Information
- Provider/Practice Name:*
- Contact Person: *
- Phone: *
- Fax: *
- Email: *
- Office Address: *
Patient Information
- Patient Name:*
- Date of Birth: *
- Phone: *
- Email: *
- Address: *
- Preferred Contact Method
- Phone Email Other *
Reason for Referral
Reason for Referral*

Psychiatric EvaluationMedication ManagementPsychotherapy ServicesADHD TestingTMS TherapySecond OpinionOther
Please Specify*
Additional Notes: (e.g., symptoms, duration, relevant medical/psychiatric history)
Insurance Information
- Insurance Provider:
- Policy Number:
- Group Number:
- Policy Holder Name:
- Relation to Patient:Self Parent/Guardian Other
Attachments (Please include any relevant documents):
Please select relevant documents that including:

Recent Visit NotesLab ResultsDiagnostic Testing ReportsMedication ListInsurance Card (Front and Back)NoneOther
Please Specify*
Additional Notes: (e.g., symptoms, duration, relevant medical/psychiatric history)
File Upload*

Cancelof
Submission Instructions
Call: 919-582-7272
Fax (Clinic): 833-941-3156
Fax (Admin): 866-533-0016
Email: info@medpsychnc.com
Signature
By submitting this referral, I confirm that I have obtained the patient’s consent to share the above information with MedPsych Integrated.
Referring Provider Signature:*

Clear
Date*

MonthDayYear
Date
Office Telephone*
Should be Empty: