Referral Form
Dr. Borue specializes in treating child and adult patients with Developmental Disorders (e.g. Attention Deficit Hyperactivity and Autism Spectrum) and/or Obsessive Compulsive Disorder . Dr. Borue will also treat patients with mood, anxiety, somatic symptom, and/or eating disorders on a case by case basis.

This form is meant to be completed by medical or mental health professionals for the purposes of referring patients to Full Spectrum Psychiatry. Referrals will be reviewed within 3-4 business days. Please note that we are not able to accommodate patients needing an urgent evaluation, seeking evaluation for disability, or those with an ongoing substance use disorder.

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Patient Information
Patient name: *
Your answer
Date of Birth: *
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YYYY
Address: *
Please include city, state, zip code
Your answer
Name of parent/guardian/POA (if applicable):
Your answer
Phone #: *
Your answer
Alternative Phone #:
Your answer
Patient's email: *
Full Spectrum Psychiatry exclusively uses digital forms. Consequently, we require our patients to have access to internet and email services.
Your answer
Referral Information
Reason for referral (check all that apply):
Does the patient have a current or suspected diagnosis of ASD (Autism, Asperger's, PDD NOS) *
Does the patient have a current or suspected diagnosis of ADHD (Attention Deficit Hyperactivity Disorder, ADD) *
Additional current diagnoses: *
Your answer
Safety concerns (please check all that apply):
Current medications: *
Please list one medication per line. Include dose, administration, duration of treatment, any known side effects.
Your answer
Previous medication trials (if known):
Please list one medication per line. Include dose, approximate dates/duration of treatment, any known side effects or reasons for discontinuation.
Your answer
Medical problems list:
Your answer
Additional comments:
Please include any specific concerns as well as any possible barriers to care such as need for an interpreter.
Your answer
Administrative Information:
Does the patient have medical insurance? *
Dr. Borue accepts Highmark, UPMC, and CCBH (Allegheny Co Medicaid)
Member #:
Your answer
(Adult patients only): Is the patient currently prescribed or anticipated to need a prescription for stimulants (Adderall, Ritalin)
For adults currently taking stimulants, Dr. Borue requires collateral information from the prescribing physician. For adults who may be starting treatment with stimulants, Dr. Borue requires completion of diagnostic paperwork and collateral information regarding childhood symptoms (from family members, teachers, or other mental health providers). All individuals who are prescribed stimulants must agree to participate in random urine drug screening.
Your Information
Name: *
Your answer
Relationship to patient *
Office phone #: *
Your answer
Email: *
Your answer
Attestation: *
By entering my initials in the box below I am digitally signing this form and certifying that the referred party is in agreement with the referral and the electronic transmission of their referral information to Full Spectrum Psychiatry. I further certify that the information provided is correct to the best of my knowledge.
Your answer
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