Rise Psychology NYC
Confidential Outpatient Clinical Referral Form
Client/Student Information
Describe the individual being referred for outpatient mental health services
Client/Student's Full Name
*
First Name
Last Name
Client/Student's Email
*
example@universityemail.edu
Client/Student's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client/Student's Age
*
Note: We currently only provide services to individuals 12 years and older.
Client/Student's Preferred Contact Method
*
Email Only
Phone Only
Phone or Email
Client/Student's Preferred Pronouns
*
She/her
He/him
They/them
Other
Is the client/student aware of this referral?
Yes
No
Other
Referrer Information
Details about the individual making the referral on behalf of a student/client
Referrer Name
First Name
Last Name
Referrer Institution or Organization
Referrer Position/Title
Referrer Email
example@example.com
Referrer Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical Information
Service Format Preferences (Check all that apply)
*
Individual Therapy
Group Therapy (if available)
Telehealth
In-Person (Midtown Manhattan)
Presenting Concerns (Check all that apply)
*
Academic/Career Stress or Transitions
Anxiety & Significant Life Changes
Concerns About Gender or Sexuality
Concerns About Health
Concerns About Race or Social Injustice
Cultural Identity/Exploration
Depression and/or Negative Feelings
Executive Functioning/Academic Difficulties
Life in General
Relationships with Friends, Family, and Partners
Sex and Intimacy Concerns
Trauma or Traumatic Experiences
Clinical Risk Concerns (Check all that apply)
Active substance use concerns
Active suicidal ideation (with or without plan)
Homicidal ideation
Psychosis or mania
Recent psychiatric hospitalization
Recent suicide attempt or self-harm
Severe eating disorder symptoms
Additional Notes / Clinical Considerations
Note: We are an outpatient, non-emergency private practice and are not equipped to provide intensive or crisis-level services If the student requires a higher level of care or urgent support please refer to appropriate emergency services.
Referral Acknowledgment
By submitting this form, I confirm that:
*
The student/client is aware of this referral (unless otherwise noted)
I understand this form is not a guarantee of services or availability
I understand this is not a crisis service and urgent needs should be directed elsewhere.
Submit
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