Primary Care Physician

Primary Care Physician
Identified Client's Name

First NameLast Name
As a policy at Capstone, therapists at Capstone Behavioral Health are required to ask and coordinate with your PCP or Primary Health Care Physician.

Contact with your PCP is an important way to keep therapist and physician informed of safety issues, medication changes, hospitalization, and discharge from treatment.
Please check one of the boxes:

I do have a PCP (Primary Health Care Physician) and will sign a Release of Information to allow coordination of care with them. Please complete the PCP information below
PCP Name:
PCP Clinic Affiliation (UNMC, Methodist, Children’s, Boys Town, CHI, etc.):
PCP Phone Number
Please enter a valid phone number.
I do have a PCP but would prefer Capstone Behavioral Health NOT have contact with them.
I do NOT have a PCP that Capstone Behavioral Health can coordinate care with.
Client/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: