haelanhealth.com - Referral Form

REFERRAL FORM

Thank you for choosing Haelan Psychiatry & Wellness!
5309 West Village Parkway Ste. 3

Rogers, AR 72758

Phone: (479) 275-4152 Fax: (479) 227-6811 Email: support@haelanhealth.com
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Patient Information
Patient Legal Name (as listed on driver’s license) *

First NameMiddle NameLast Name
Patient Preferred Name
Patient’s Date of Birth*

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Date
Gender Assigned at Birth*

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Gender Identity / Pronouns

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Home Address*

Street Address

Street Address Line 2

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Postal / Zip Code
Email Address*
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Phone Number*
Please enter a valid phone number.
Referral Details
Reason for Referral*
Clinical Documentation Upload
For clinical referrals, please attach relevant medical records and medical history.

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Clinical Information
Psychiatric Diagnosis(es)
Psychotropic Medication History*

Not currently taking psychotropic medicationsAbilify (Aripiprazole)Adderall (amphetamine/dextroamphetamine)Ambien (Zolpidem)Ativan (Lorazepam)Buspar (Buspirone)Celexa (Citalopram)Cymbalta (Duloxetine)Effexor (Venlafaxine)Klonopin (Clonazepam)Lamictal (Lamotrigine)Lexapro (Escitalopram)Paxil (Paroxetine)Pristiq (Desvenlafaxine)Prozac (Fluoxetine)Remeron (Mirtazapine)Seroquel (Quetiapine)Strattera (Atomoxetine)Vistaril (Hydroxyzine)Vyvanse (Lisdexamfetamine)Wellbutrin (Bupropion)Xanax (Alprazolam)Zoloft (Sertraline)Zyprexa (Olanzapine)Other:
Referring Provider Information
Referring Provider Name*
Facility Name*
Facility Address*
Referring Provider Contact Number*
Please enter a valid phone number.
Contact Person Name*
(If different from provider)
Referring Provider Email Address *
example@example.com
HIPAA Privacy Notice

This form may contain protected health information (PHI) intended solely for the use of the individual or entity to which it is addressed. If you are not the intended recipient, you are hereby notified that any review, disclosure, copying, distribution, or use of this information is strictly prohibited. If you have received this information in error, please notify the sender immediately and destroy all copies.

By submitting this referral, the referring provider confirms that the patient has been informed of and has authorized the disclosure of relevant health information for the purpose of care coordination, treatment, and related healthcare operations, in accordance with HIPAA regulations.
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Date*

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Haelan Psychiatry & Wellness
5309 West Village Parkway, Ste. 3 | Rogers, AR 72758
📞 (479) 275-4152 | 📠 (479) 227-6811 | 📧 support@haelanhealth.com

This form contains protected health information and is intended for authorized use only. HIPAA compliant.
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REFERRAL FORM

Patient Information

Referral Details

Clinical Documentation Upload

Clinical Information

Referring Provider Information