Clear Path Psychiatry PLLC Referral Form

Referring Provider Name & Credentials:

Practice/Organization Name

Phone number

Fax Number

Secure Email address

Patient Full Name

Patient Date of Birth (DOB)

Patient Phone Number

Insurance / Coverage (if applicable):

Reason for Referral (check all that apply)

Anxiety Disorder

Depression

PTSD / Trauma-related disorder

Medication Management

Diagnostic Clarification

Other Referral reason:

Patient Clinical Information

Current Medications

Pertinent Psychiatric/Mental Health History

Medical Conditions (if relevant)

Safety Concerns (suicidality, homicidality, psychosis, etc.):

Urgency of Referral

Routine (2–4 weeks)

Urgent (within 1 week)

Crisis (same day – call first at (507) 654-0020)

Attachments (optional) Upload relevant progress notes, lab results, or medication lists.

Add file

Please upload a file

Authorization & Consent

I confirm I have obtained the patient’s consent to share this information with Clear Path Psychiatry PLLC.

Electronic Signature (Type full legal name)

By typing your name here, you are providing your electronic signature and confirming the accuracy of the referral information.

Your information will be encrypted.

Telephone 507-654-0020, Fax: 507-322-7259, Secure Email: support@clearpathpsychiatrymn.com
www.clearpathpsychiatrymn.com
100 S. 2nd St, Suite B, Eagle Lake, MN, 56024, United States