New Client Referral

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New Client Referral

If you are an existing client or a collaborating therapist wanting to refer a new client to my Telepsychiatry practice, please fill out this form. Thank you for your referral.

Are you an existing client or a collaborating therapist? *

Existing Client

Collaborating Therapist

What is your name? *

What is the new client's full name? *

What is the new client's date of birth?

What insurance does the new client have?

Private Pay (Cash)

Commercial Insurance (HMO/PPO)

Government-Sponsored Insurance (Medi-Cal/Medicare)

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What is the reason that you are referring this new client?

Psychotropic Medication Management

Psychotherapy (Talk Therapy)

Medication Management & Talk Therapy

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What mental health condition does this new client have?

Mood Disorders (anxiety, bipolar, depression)

Psychotic Disorders (schizophrenia, paranoia/delusion)

Cognitive/Developmental Disorders (dementia, ADHD, ASD)

Substance Abuse Disorders (alcoholism, benzo/stimulant abuse)

Unknown/Undiagnosed Mental Disorder

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What is the new client's best-reach phone number or email? *

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