Professional Referral Submission

Professional Referral Submission

“For licensed providers referring patients for psychiatric evaluation and medication management.”
Full Name - Referring provider information *

First NameLast Name
Credentials (MD, DO, LICSW, LMHC, etc)*
Practice/Organization Name*
Email*
Secure Clinical Email Address
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name - Patients Full Name*

First NameLast Name
Patients Date of Birth*

MonthDayYear
Date
Primary Insurance (if known)
Current Therapist (if applicable)
Is the patient aware of and consenting to this referral? *
No acute safety concernsActive Drug or alcohol concernsActive SIRecent hospitalization
Date

MonthDayYear
Date
This referral may not be appropriate for outpatient psychiatric consultation. Please contact emergency services or higher level of care

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Upload Supporting Documentation for example: Most recent progress note, medication list, labs, testing, or relevant records.

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Provider Attestation - I confirm that the patient has consented to this referral and to the exchange of clinical information for coordination of care. I understand this submission will be reviewed prior to scheduling.*
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