Mental Health Referral Form (website)

Mental Health Referral Form
Legal Name:

First NameLast Name
Preferred Name:

First NameLast Name
Preferred Pronouns:
Sex:

MaleFemale
Date of Birth:

MonthDayYear
Date
Preferred Language:
Translator Needed?

YesNo
Guardian/Conservator (If Applicable):

First NameLast Name
Address (Physical):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address (Mailing):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Primary):
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Alternate):
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Insurance Carrier:
Member Policy #:
Name of Insured:

First NameLast Name
Insured Date of Birth:

MonthDayYear
Date
Relationship to Patient:
Secondary Insurance:
Policy #:
Has patient been informed that provider is referring them to a mental health provider?

YesNo
Reason for referral:

Medication Management (Psychiatry)Therapy
Which location would you like to be seen at?

ReddingRed BluffEurekaFairfieldMontereySalinasHollisterHomePsych (online)
Referring Provider/Clinic:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Please enter a valid phone number.Format: (000) 000-0000.
Form Completed By:
Date:

MonthDayYear
Date
Please Fax Completed Form to NAMHS Centralized Scheduling at (530)722-4544

1742 Oregon Street, Redding, CA 96001 Phone +1 (888) 292-8080

Email: appointment@namhs.com
Should be Empty: