Clear Path Psychiatry PLLC

100 S. 2nd Street, Suite B, P.O. BOX 47, Eagle Lake, MN 56024

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Phone: (507) 654-0020
Fax: (507) 607-8815
Secure Email: support@clearpathpsychiatrymn.com
Website: clearpathpsychiatrymn.com

Clear Path Psychiatry Referral Form

Referring Provider Name & Credentials:

Practice/Organization Name

Contact Phone Number

Fax Number

Patient Full Name

Patient Date of Birth (DOB)

Patients Best Contact Phone Number

Reason for Referral (check all that apply):

Anxiety Disorder

Depression

PTSD / Trauma-related disorder

Medication Management

Diagnostic Clarification

Transfer of psychiatric care

Other (please specify):

Other Referral reason:

Current Safety Assessment

No current safety concerns

Passive suicidal ideation without plan or intent

History of suicidality, currently stable

Active suicidal or homicidal ideation, acute psychosis, or imminent safety risk

Clear Path Psychiatry provides outpatient, non-crisis care. Patients with acute safety concerns should be referred to emergency services or local crisis resources.

Helpful attachments (if available): Progress notes, H&P, discharge summaries, medication list, relevant labs or EKGs, prior psychiatric evaluations.

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Authorization & Consent

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

Name of person submitting this form (provider or authorized staff)

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Phone: (507) 654-0020
Fax: (507) 607-8815
Secure Email: support@clearpathpsychiatrymn.com
Website: clearpathpsychiatrymn.com

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