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Professional Referral

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Mental Health Referral Form

**If your patient has an urgent mental health need, please call and we will see them in the same day for a walk-in appointment**

Phone: (719)493-9555
Secure Fax: 719-284-4627
Email

3720 Sinton Rd.,
Suite 104,
Colorado Springs, CO 80907

To submit a referral please fill out and submit the form below

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Patient Information

Patient Name*:

Gender:MaleFemaleOther

Date of Birth*:

Phone Number*:

Email*:

Insurance*:

Policy Number*:

Symptoms

Check all the Appropriate Symptoms*
Depressed MoodExcessive fears/worriesWithdrawl from friends/activitiesDetachment from reality *urgentMajor changes in eating habitsSuicidal thinking *urgentConfused thinkingExtreme feelings of guiltSignificant tirednessDelusionsInability to cope daily stressorsSex drive changesReduced concentrationExtreme mood changes (highs/lows)Low energy or trouble sleepingParanoiaProblems with alcohol/drug abuseExcessive anger or violence
Other:

Services

Service Requested*
(check all that apply)
Psychiatric Assessment and TreatmentMedication ManagementChronic Mental Health ManagementGenetic TestingMentally STRONG Method Cognitive Behavioral CounselingSPRAVATOSpecial Needs, IDD SpecialistClozarill ManagementVIVITROLPaperwork(HRC,PASA,SSI)Pediatric Treatment

Specific Notes:

Referral Information

Name*:

Organization*:

Electronic Signature*

I confirm the typed name above is my electronic signature

Today's Date*:

Mentally STRONG
Office: (719) 493-9555
Fax: (719) 284-4627

3720 Sinton Rd Suite 104
Colorado Springs, CO 80907

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