Integral Psychiatry Referral Form
For Providers
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Referring Provider Name: *
Referring Provider Practice: *
Referring Provider Contact Email:
Referring Provider Fax:
Patient Name: *
Patient Date of Birth: *
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Patient Phone Number *
Patient Email Address:
What form of treatment is the patient currently interested? *
Which of the following best describes the patient's current health insurance status? *
Required
How did you hear about us? *
Does the patient have any medical conditions? *
Is the patient currently on any medications? *
Click the box below to confirm that you (the individual filling out this form) are a representative of the patient requesting care from Integral Psychiatry, PLLC *
I understand that Integral Psychiatry, PLLC currently only schedules patients aged 18 through 60  *
Click the box below to state that you are aware that a doctor-patient relation is NOT formed with a new patient request consultation or an initial evaluation. A doctor-patient relationship is formed if Integral Psychiatry, PLLC and the prospective patient decide to establish care after the initial evaluation *
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