Referral Request Form
Enter referring provider and patient details, referral reason, and any supporting records.
Referring Provider Information
Name and credentials
*
Practice / Organization
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Fax
Referring Clinician NPI
Patient Information
Is the patient under 18?
*
Yes
No
Full name
*
First Name
Last Name
Preferred name (if applicable)
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient email
example@example.com
Preferred contact method
*
Phone
Email
Either
I confirm the patient has agreed to be contacted
*
Agreed to be contacted by Nexus
Agreed to be contacted by a referral partner
Parent/Guardian Information
Parent/Guardian name
*
Relationship to patient
*
Parent/Guardian phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian email
*
example@example.com
Clinical Information
Reason for referral
*
Current diagnoses
Current medications
Urgency
*
Routine
Urgent (non-crisis)
Service requested
*
Psychiatric evaluation
KAP Evaluation
Adult Psychiatry & Medication Management
Adolescent Psychiatry & Medication Management
SPRAVATO®
Psychotherapy
Other
Provider Requested (if applicable)
SOONEST AVAILABLE
German Ascani, MD
Harry Chiang, PhD, MSCP
Lindsay Shaw, EdD, MSCP
Laura Richardson, PhD, MSCP
Visit preference
In person
Telehealth
Either
Unknown
Does the patient have a current therapist?
Yes
No
Therapist name (if applicable)
Coverage Information
Insurance
Member ID
Insurance card (upload)
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Records
Recent notes or records (upload)
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Additional Details
Administrative Notes / Comments (if applicable)
Attestation
I confirm this is not a crisis referral. For urgent safety concerns, please contact 911 or 988.
*
I acknowledge and agree
Submit Referral
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