Iron Ridge Recovery — Clinician Referral
Submit referral details for a licensed clinician to coordinate next steps for a men’s intensive outpatient program.
About you (the referring clinician)
Your name
*
First Name
Last Name
Credentials (e.g., LPC, LMFT, PsyD)
*
Practice or organization
City and state
Email address
*
example@example.com
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Best time to reach you
About the referral
Client reference or initials only
*
Client city and state
Is the client aware of this referral?
Yes
No
Not yet discussed
What is prompting the referral now?
*
Relevant clinical context
Are there current safety concerns, such as suicidal or homicidal ideation?
No known concerns
Yes, please call me
Unsure
Preferred next step
Call me to discuss
Email me
Have the client contact you directly
Anything else we should know
Acknowledgment
*
I understand this form is for initial referral coordination only, and that clinical records will be exchanged only after a signed release of information is in place.
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