CIP Psychiatry – Patient Referral Form
Note: This referral form is for providers. Patients experiencing an emergency should call 911 or go to the nearest emergency department.

Thank you for referring your patient to CIP Psychiatry!

Please fill out the following form and one of our patient care coordinators will reach out to your patient within 48 business hours. 

Please send any relevant chart notes, labs, or documentation by one of the following secure methods:

    •    Encrypted email → info@cipclinic.com

    •    Fax → (947) 222-9473

    •    Direct to patient → Patients may upload documents into their secure portal once they are set up in our system.

By submitting this referral, you acknowledge that you are authorized to share this patient’s information for treatment purposes under HIPAA. You confirm that the patient has consented to being referred to CIP Psychiatry and to being contacted directly by our clinic for scheduling and coordination of care. CIP Psychiatry will use the information provided solely for treatment, payment, and healthcare operations, in compliance with HIPAA and applicable state laws.

Learn more about our Privacy Policy here.

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Please write out your name or your practice's name. 

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Please write out the name of your specialty (Therapist, Psychologist, Primary Care, etc)

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Please write out your contact number or the contact number for your office. If you'd prefer not to share this, please write "N/A".

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Please write out your email address or the email address for your office. If you'd prefer not to share this, please write "N/A".

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What is your patient's full name?  *
What is your patient's Date of Birth? *
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What is your patient's phone number? *
What is your patient's email address? *
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