Patient Referral Form

Patient Referral Form

We welcome referrals and collaboration from outside provider teams. In an effort to streamline the process for all involved, please complete the following information as thoroughly as possible (this minimizes repeat back-and-forth and expedites the process for your patient)! *The form is HIPAA compliant/secure.
*Once reviewed, our team will reach out to the patient for scheduling. *Should the referral be deemed inappropriate for our clinic at this time, you will be notified immediately. By submitting thorough referral requests via this form, our team can review and respond within 2 business days in most cases.
*Please do not submit a referral for the same patient more than once. If you have questions/concerns about a patient you've already referred, please contact our office.
Preferred Hearthstone Psychiatrist:*
Section 1

Referring Provider Info
Referring Provider Name*

First NameLast Name
Referring Practice Name*
Preferred Practice Contact

First NameLast Name
Practice Contact Email*
example@example.com
Practice Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Practice Fax*
Please enter a valid fax line number.Format: (000) 000-0000.
Family PractitionerInternistMental Health CounselorObstetrician/GynecologistNeurologistOther
Section 2

Patient Info
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
MaleFemaleOtherChoose not to disclose
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email*
example@example.com
Patient Address*

Street Address

Street Address Line 2
CityStateZip Code
Section 3

Patient Insurance Info
Insurance Company
Insurance Subscriber

First NameLast Name
Member ID (if self-pay, type n/a)*
Group Number (optional)
Front image of patient's insurance card

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Back image of patient's insurance card

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Section 4

Reason for Referral
Diagnostic Clarification Consult (patient will return to referring clinician for ongoing management)Complex Medication ConsultOngoing Psychiatric ManagementTreatment-Resistant SymptomsADHD Evaluation and/or TreatmentBipolar Spectrum EvaluationTrauma-Related ConditionsOther
Brief Description*
Section 5

Urgency/Safety Screening
Active Suicidal Intent or PlanRecent Suicide Attempt (past 30 days)Acute Psychosis with Safety ConcernsSevere Substance/Alcohol Withdrawal RiskNone of these - proceed with referral form
Urgency for Appointment
*Urgent requests will be accommodated when at all possible but cannot be guaranteed
If *Urgent was selected for Appointment, please briefly explain (urgent requests with no explanation will be treated as routine)
Section 6

Current Medications
Please list current medications (or upload list below)
Upload current medication list

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Section 7

Past/Current Mental Health Treatment
Currently in Therapy?
Has the patient ever seen a psychiatrist?
Has the patient ever been hospitalized for psychiatric reasons ever in lifetime?
Section 8

Attach pertinent records
Any Additional Notes
Is there anything else we may need to know for review of this patient? (history of aggression, comorbid substance use, concern for self harm/NSSI, psychosocial dynamics, etc).
THANK YOU!

We appreciate your time in making this referral process as streamlined as possible for your patient. Submission of this info will generate an immediate review by our team. Again, if referral is approved, we will reach out to the patient for scheduling within 2 business days. If declined for any reason, or if any additional information is required, you will hear from us via your practice contact info provided above.
I acknowledge and agree
Should be Empty:

Patient Referral Form

*Please do not submit a referral for the same patient more than once. If you have questions/concerns about a patient you've already referred, please contact our office.

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THANK YOU!