Professional Referral Form
Thanks for referring your patient to us for mental health care. We need some basic demographic, insurance, and clinical information to process the referral. All information submitted here is confidential and HIPAA-compliant.
PLEASE NOTE - WE ARE CURRENTLY SCHEDULING NEW PATIENT APPOINTMENTS INTO JANUARY 2019 DUE TO HIGH DEMAND AND THE UPCOMING HOLIDAY BREAK FOR OUR STAFF. PLEASE BE PATIENT AS WE PROCESS NEW PATIENT REGISTRATIONS AND TRY TO MANAGE OUR WAITLIST. WE WILL CONTACT EVERYONE IN JANUARY (IF NOT SOONER) AS OPENINGS COME AVAILABLE.
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 primary Medicaid (other than UHC Community Plan or CareSource) for insurance coverage, as we do not accept any other forms of Medicaid plans at this time.
Patient has primary Medicare (other than a commercially branded type of Medicare (like UHC Medicare, Aetna Medicare, Anthem Medicare, MMO Medicare, Humana Medicare, etc)), as we are not credentialed to accept "paper" 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.
NONE OF THESE ARE TRUE
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