Internal Clinic Referral Form
Internal Use Only Instructions: Please complete this form to alert our office manager/scheduler about patients who need additional services. Once this form is submitted, the patient will be contacted by email to be notified of a slot or their position on the waiting list. No further action is needed from the provider upon submission of this form.
Clinician Information
Supply information of the provider submitting the form
Submitter Name
First Name
Last Name
Enter the patient's initials in the following format (Jane Doe = J. Doe)
Submitter Email
example@example.com
Relationship to the Patient
Patient Information
Name
First Name
Last Name
Patient Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Services
What service(s) does the patient CURRENTLY receive?
Individual Therapy
Couple Therapy
Family Therapy
Group Therapy
Medication Management
Other
What services does the patient need?
Individual Therapy
Couple Therapy
Family Therapy
Group Therapy
Medication Management
Discharge/ File Closeout
Other
Which services is the patient being discharged from?
Individual Therapy
Couple Therapy
Family Therapy
Group Therapy
Medication Management
ALL SERVICES - CLIENT IS BEING DISCHARGED FROM CLINIC
Is the patient currently registered in our EHR?
Yes
No
What is the primary reason for the referral/request?
Patient needs additional care
Specialized Treatment Requested
Clinician Requested - Not a Good Fit
Patient Requested - Not a Good Fit
Scheduling Conflict
Client Disengaged
Other
Our patient care team needs to be able to match your patient to the appropriate level of care. Please rate the acuity or clinical functioning of the patient.
Level 1 - Low Risk/Low Complexity - Intern
Level 1.5 Low Risk / Moderate Complexity - Intern
Level 1.75 Low Risk/ High Complexity - Intern
Level 2 Moderate Risk/ Low Complexity - LG
Level 2.5 Moderate Risk/ Moderate Complexity - LG/LC
Level 2.75 Moderate Risk/ High Complexity - LC
Level 3 - High Risk - Crisis Diversion
Level 3.5 - High Risk/High Complexity - Clinical Supervisor Only
Other
Please list any details, preferences, or special requests
Submit
Should be Empty: