RPC Austin Referral Form
This referral form is confidential. In compliance with the Health Portability and Accountability Act "HIPAA" (rule 104-91), please know that communications over the internet are not guaranteed to be secure. There exists a possibility that information you include in this form can be intercepted and read by other parties besides the staff at RPC Austin. Please call us at 512-982-4116 if you prefer to refer a patient by phone.
Referring Provider Name:
Clinic/Office Name (If Applicable)
Referring Provider Phone Number
Referring Provider Fax Number
Referring Provider Email
What service are you referring your patient for?
Therapy or counseling
One time medication or psychiatric consult
Medication management and therapy
Third Party Reproduction Consult
Reason for Referral
Is there a specific provider you are referring your patient to?
Kristin Lasseter, MD
Nichelle Haynes, DO
Carmen Colomer, MD (bilingual)
Nicole Scott, MD
Elaine Cavazos, LCSW, PMH-C
Sarah Deal, PhD, LPC
Grace Rao, LMSW
Emily Obront, LMSW
Patient Date of Birth
Patient Phone Number
Patient's Email Address
Patient's Current Health Insurance Provider
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This form was created inside of Reproductive Psychiatry Clinic of Austin.