Integral Psychiatry Referral Form

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For Providers

Referring Provider Name: *

Referring Provider Practice: *

Referring Provider Contact Email:

Referring Provider Fax:

Patient Name: *

Patient Date of Birth: *

YYYY

Patient Phone Number *

Patient Email Address:

What form of treatment is the patient currently interested? *

Medication Management and Therapy

Therapy only

Medication Management only

Do not know/Undetermined

Which of the following best describes the patient's current health insurance status? *

Health Choice

Other Private Insurance (i.e. BCBS, United, Aetna, Cigna, etc.)

Medicare (i.e. Medicare, Managed Medicare)

Medicaid (i.e. Soonercare)

Uninsured

Other:

Required

How did you hear about us? *

Social Media

Google

Psychology Today

Referral

Other:

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 *

Click here to confirm

I understand that Integral Psychiatry, PLLC currently only schedules patients aged 18 through 60 *

Click here to confirm

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 *

Click here to confirm

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This form was created inside of Integral Psychiatry.