Professional Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thanks for referring your patient to us for mental health care. We need some basic demographic, insurance, and clinical information in order to process the referral. All information submitted here is confidential and HIPAA-compliant.

Name of Referring Clinician/Clinic/Office/ER/Hospital: *

Please note: If any of the following are true, we will unfortunately not be able to accept the referred patient into our practice, and it would be better to refer the patient elsewhere: *

Patient's primary issue is substance use, as that is not our specialty.

Patient's treatment is court-ordered, as we don't do court-ordered treatment.

Patient is taking a benzodiazepine (Ativan, Klonopin, Valium, etc) and wishes to continue taking it, as we do not prescribe benzodiazepines or sleep medications.

Patient is younger than 3 or older than 55, as we do not see patients younger than 3 or older than 55.

Patient has Medicare, as we are not credentialed to accept any form of Medicare.

Patient has any legal problems, court disputes, charges, or law suits that may require our staff to get involved, as we do not render opinions for court or provide letters for attorneys.

Patient is involved in a custody dispute and parents want us to get involved, as we won't render opinions regarding custody arrangements.

Patient thinks they have ADHD, wants a stimulant, and is unwilling to undergo psychological testing to verify the diagnosis, as well as attend a 4-session ADHD skills group before medication is given.

Patients who are receiving injectable medications must have arrangements to receive these medications elsewhere, as we do not have any means to give them in our offices.

Patients who are currently off work on mental health disability or are seeking such disability as we do not complete disability forms and do not write patients off work for mental health reasons.

NONE OF THESE ARE TRUE

Required

Please note: If your patient is using medical marijuana and doesn't agree with our medical marijuana policy found here: www.providersforhealthyliving.com/medicalmarijuana, they will not be a good fit for our practice. *

This patient doesn't use medical marijuana.

This patient has been informed of your medical marijuana policy.

Clear form

Never submit passwords through Google Forms.

This form was created inside of Providers for Healthy Living, LLC. Report Abuse

Forms