Refer a patient

We welcome referrals from healthcare providers, including primary care physicians, therapists, and other specialists. To refer a patient to our clinic for psychiatric or addiction services, please complete the referral form. This referral form is for non-urgent mental health concerns only. Do not use this form for patients experiencing an acute mental health crisis. For emergencies, contact 911 or the Suicide & Crisis Lifeline at 988 immediately.

Patient's First Name, Last Name

Patient's Date of Birth

Patient’s Contact Number

Referring Provider’s Name and Title

(e.g., Dr. Jane Smith, Psychiatrist or John Doe, LCSW).

Referring Provider's Email

Reason for Referral Please specify the primary reason for referral

Psychiatric evaluation

Medication management

Addiction services

Second opinion

Therapy services

other

Additional Notes (Optional)

Relevant clinical history or additional information that may assist in evaluation and treatment:

Your information will be encrypted.

Refer a patient

Refer a patient

Refer a patient

Connect Psych Network, PLLC