Professional Referral Form

Professional Referral Form
Please use this referral form to provide information on the clients you are referring to Inner Healing Consulting.

(This form is HIPAA compliant. All information submitted is encrypted and securely transmitted in compliance with federal privacy laws. You can also Fax Referrals to our HIPAA compliant Fax# 734-274-4554)
Referrer Information
Referrer Full Name: *

First NameLast Name
Company/Practice Name:*
Phone:*
Please enter a valid phone number.
Fax:*
Email: *
example@example.com
Preferred Method of Contact:*

PhoneEmailFax
Patient Demographics
Patient Full Name:

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Gender:*

MaleFemaleNon-Binary
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Insurance Information
Insurance Carrier:*
Plan/Policy #:*
Group #:*
Authorized # for HMO:
Upload Insurance Card Front

Cancelof
Upload Insurance Card Back

Cancelof
Clinical Information
Reason for Referral*

Psychiatric EvaluationMedication ManagementBrief Therapy/CounselingSubstance Use EvalAnger Management EvaluationBariatric EvaluationImmigration EvaluationOther
Chief Complaint*
Current Diagnosis (ICD-10) *
Risk Factors*

Suicidal IdeationHomicidal IdeationSubstance WithdrawalRecent HospitalizationNone
Current Medications:*
Allergies:*
Attach Clinical Documentation (optional):

Cancelof
Urgency Level
Urgency Level

Routine (appointment within 2–4 weeks)Expedited (appointment within 7 days)
We do not accept Urgent Mental Health Emergency Clients. If the client needs Immediate/Urgent
Mental Health Emergency please call 988, for the Suicide & Crisis Lifeline.

If you are experiencing a life-threatening emergency, please call 911, or go to the nearest Emergency Room
Authorizations
Term & Condition*

I, the referrer, confirm I am authorized to share this information for treatment purposes.Patient/guardian has provided consent to share information.
Signature (Referrer/Company or Authorized Staff): *

Clear
Date*

MonthDayYear
Date
Should be Empty:

Professional Referral Form

Referrer Information

Patient Demographics

Insurance Information

Clinical Information

Urgency Level

Authorizations