Patient Referral Form

Please complete this form to refer a patient to a psychiatrist at Comprehensive Psychiatric Services.

Today's date

Referring provider name

Referring clinic/hospital name

Referring provider's contact phone number

Referring provider's contact email

Referring office email/fax # for records

Patient Information

Patient's full name

Patient's date of birth

Month

Day

Year

Patient's insurance provider

Patient's policy/ID number

Patient's contact phone number

Patient's contact email

Urgency of referral

Routine (Within 1-2 weeks)

Urgent (Within 3-5 days)

Relevant clinical summary and reason for referral

Attach relevant labs/imaging/reports

Please upload images or documents only (e.g., lab results, imaging reports, clinical notes).

Yes, the patient is aware and agreeable to this referral