OUTPATIENT REFERRAL REQUEST FORM

OUTPATIENT REFERRAL REQUEST FORM

Items with an asterisk (*) are required for processing.
Type of Care:

RoutineUrgentEmergentSpecialtyPreventative
Please provide all necessary information needed to communicate with this patient. We will assume the patient listed in this form has expressed interest in receiving outpatient mental health, psychiatric, or primary care services. If available, please include any relevant document related to this referral.

All referrals will be processed within two business days. To check on the status of a referral, please call 910-777-5575 ext. 101. Our referral line is staffed Monday through Friday from 9:00am to 6:30pm. For immediate assistance, please call us at 910-777-5575, ext. 103, after faxing or emailing this form.
Referring Facility Information
Name:
Referred By:
Phone:
Please enter a valid phone number.
Today’s Date:

MonthDayYear
Date
Diagnosis/ICD10:
Order:
Reason:

Transfer of CareConsultation or ScreeningEmployee AssistancePsychoeducationImmigration EvaluationGroup TherapyCourt-ordered TreatmentCrisis InterventionRelapse PreventionSubstance Use DisorderAnger ManagementPsychotherapyPsychological EvaluationEMDR / Trauma TreatmentBiofeedbackPsychiatric TreatmentPrimary Care ServicesGenetic/Lab Testing
Patient Information
Patient Name:*
Date of Birth:

MonthDayYear
Mailing Address:*
Gender:

FemaleMale
Telephone:
Please enter a valid phone number.
Mobile:
Please enter a valid mobile number.
Insurance Name:
ID:
Insurance Name:
ID:
Is the patient aware of this referral?

YesNo
Functional and Cognitive Status
Comment:
Thank you for your referral.

Confidentiality: This information is solely for the intended recipient and may contain confidential information which is, or may be, legally privileged or otherwise protected by law from further disclosure. If you are not the intended recipient, any disclosure, copying, use, or distribution of the information included in this letter is prohibited. If you have received this communication in error, please notify the sender by reply mail and immediately and permanently destroy it.
Should be Empty:

OUTPATIENT REFERRAL REQUEST FORM

Referring Facility Information

Patient Information

Functional and Cognitive Status