For your safety, our office staff is fully Covid-19 vaccinated.
Name of referring practice/group/organization
City
Phone
Referring Provider Email
Patient Name
Sex MaleFemale
Date of Birth
Address
Best Phone Number
Other
Group #
Name of Insured
Relationship to patient
Preferred Community Psychiatry Location Has patient been informed that provider is referring them to a psychiatrist? YesNo Provider Preference No Credential PreferencePsychiatric Nurse PractitionerPsychiatristProvider Gender PreferenceNo Gender PreferenceMaleFemale
Reason for Referral Psychiatric & Medication EvaluationTherapy/CounselingPsychiatric & Med Evaluation And TherapyTranscranial Magnetic Stimulation (TMS)
Note: We do not accept workers compensation or disability evaluations
Explanation of Patient’s Mental health Diagnosis or Symptoms / Diagnosis codes
Current Medications
Form Completed By Fax