Referal Psychiatric Referal Form Referring Provider Name: Clinic/Practice Name: Phone: Fax: Email: Patient Name: Date of Birth: Gender: SelectFemaleMaleOtherPrefer not to say Marital Status: Single Married Divorced Widowed Address: Patient Phone: Emergency Contact Name & Relationship: Emergency Contact Phone: Insurance Provider: Policy Number: Social Security Number: Group Number: Subscriber Name: Reason for Referral: Diagnostic Evaluation Medication Management Crisis Intervention Other (please specify below) Other Reason: Presenting Problem(s): Depression Anxiety Psychosis Mood Swings Suicidal Ideation Homicidal Ideation Substance Use Cognitive Decline PTSD/Trauma Other (please specify below) Other Presenting Problem: Relevant Medical/Psychiatric History: Current Medications: Medication Name Dosage Frequency Risk Factors: