PROVIDERS: REFER A PATIENT

Date of Referral

REFERRAL SOURCE INFORMATION

Referring Provider Name

Phone

Email

How did you hear about us (CopeWell Psychiatry & Wellness)?

PATIENT INFORMATION

Patient First Name

Patient Last Name

Patient Email

Patient Address Line 1

Patient Address Line 1

Patient City

Patient State

Patient Zip

Patient Home Phone

Patient Cell Phone

Patient Marital Status Patient Marital Status Married Single Divorced Widowed

Patient Sex Patient Sex Male Female

CLINICAL INFORMATION

Reason for Referral

Primary Psychiatric Diagnosis Primary Psychiatric Diagnosis Diagnosis Confirmed Diagnosis Suspected

INSURANCE INFORMATION

Do you have the client's health insurance information? (required) Do you have the client's health insurance information? (required) Self Pay/Out of Network Primary Insurance Secondary Insurance FSA/HSA Uninsured

Please add insurance Information is applicable:

Is there anything else you'd like us to know?