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New Patient Referral Form
Thank you for entrusting us with your client/patient. Upon submission of this form, a staff member will contact the patient within 48 business hours. A patient in active crisis should NOT be referred to Re-Integrate Mental Health & Counseling. Call 911 or send patient to nearest emergency room.
Service(s) that client is seeking:
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Psychiatry/Addiction Medication Management
Mental Health Counseling
Both Psychiatry/Addiction Medication and Counseling
Client Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Client E-mail
*
example@example.com
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason client is seeking mental health treatment. Include any current/past medical and mental health history, and medication treatment. If the client is being referred by a Hospital, Residential Treatment, and/or Psychiatric Emergency Treatment, please provide reason for admission and treatment.
*
Upload supporting documents (ROI, Demographic/Facesheet, Medication List, Psych Evaluation, Progress Note, etc.)
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of
Name of Provider/Person Completing Form
*
Example: Person Name, Tittle/Role/Relationship (MD/NP/Therapist, etc), Hospital/Treatment Center
Phone # of Referring Provider/Organization
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address of Referring Provider/Organization
*
example@example.com
ReIntegrate Mental Health & Counseling, PLLC
New Patient Referral Form
Updated 11.3.2025
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