Patient Referral Form

Patient Referral Form

Phone: (210) 940-2764 | Fax: (830) 239-9930 | Email: referrals@alamopmh.com
Referring Organization Information
Referring Organization Name*
Referral Date*
Organization Type*

Clinic/ HospitalSchoolCommunity OrganizationOther
Referral Representative

APMHC may contact regarding this referral
Name*

First NameLast Name
Role*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Fax Number
Please enter a valid phone number.
Institution Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information
Name*

First NameLast Name
Date of Birth*
Patient Age*
Email
example@example.com
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Phone Number*
Please enter a valid phone number.
Preferred Language*

EnglishSpanishAmerican Sign Language (ASL)Other
Preferred Communication Method
Insurance Name.
Insurance Policy No.
Parent/ Guardian Information

(If Patient is under 18)
Parent or Guardian Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Email Address
Parents, guardian, mother, father, family relatives
Reason for Referral
Primary Reason (s) for Referral (Check all that apply)*

AnxietyDepressionADHDBehavioral ConcernsTrauma/ PTSDOther
Health Status
Medical Diagnosis
Brief Description of Concerns
Urgency and Safety Screening
Is this referral urgent?

YesNo
Any known Safety Concerns? Check all that applies*

Suicidal IdeationSelf-harmAggressionNot SureOther
Services Requested

Check all that applies
Our Services

Psychiatric EvaluationMedication ManagementTherapyADHD Diagnostic or Clinical AssessmentTelehealth Services
Preferred Appointment Preference

In Office AppointmentTelehealth AppointmentFlexible
Please list the medication the patient is currently taking
Health Care Provider Details
Provider Name

First NameLast Name
Provider Phone Number
Please enter a valid phone number.
Physician Email
example@example.com
Consent and Acknowledgement
I confirm that the patient and/or legal guardian is aware of this referral and has
consented to being contacted by Alamo Premier Mental Health Clinic (APHMC).
Name of Person Completing this form*
Date Signed*
Signature*

Clear
Patient records should be faxed or emailed to Alamo Premier Mental Health at:
Fax: (830) 239-9930
Email: referrals@alamopmh.com
Should be Empty:

Patient Referral Form

Referring Organization Information

Referral Representative

Patient Information

Parent/ Guardian Information

Reason for Referral

Health Status

Urgency and Safety Screening

Services Requested

Health Care Provider Details

Consent and Acknowledgement