Medication Referral Form

WELCOME! Thanks for think of us for your client's medication management. Be aware that we do not accept crisis intakes for medication management. If the client is in crisis or at risk of self harm, please call 911 or send the to the nearest psychiatric intake center.

We respond quickly. Our care coordination staff will review your referral and contact the client within 1-2 business days at most. If by the third business the client has not heard back, something has gone wrong. Have them email fpscare@fpssecure.com to follow up or call our office at 785-371-1414.

Your (the provider's) Name

Client's First Name

Client's Last Name

Your (the provider's) Email Address. We will contact you via secure email

Age of Client

Date of Birth of Client

Gender of Client

City

State

Zip Code

Client's Email Address (Enter correctly. This is how we will contact them) address

SERVICE MODALITY

In Office Telehealth

(NOTE: Telehealth is only offered for qualified clients over 18-years-of-age living in an underserved area of Kansas sixty miles beyond Lawrence)

PREFERRED PHMNP (We will attempt to honor your preference, but we can't guarantee availability of a given staff person)

Gilah Weissman, APRN PHMNP Oleg Mironchenko, APRN PHMNP No preference

If you have a photo or scan of the front of the client's insurance card, please upload it by clicking the "choose file" button below. This is helpful but not mandatory. If the client has already applied at our office for services, this is not necessary.

Choose File

Add file

Please upload a file

Does the client have secondary Insurance?

No, client does not have secondary insurance Yes, client has the following secondary insurance

Secondary Insurance Company

Generally speaking, what is the current diagnosis on file with your office?

ADHD Anxiety OCD Depression Bipolar Disorder Borderline Personality Disorder Behavioral Disorder Issues Related to Reproduction Adjustment Disorder

DETAILED SYNOPSIS OF CLIENT NEED: What brings your client to see us? What has been the client’s medication experience thus far? How do you see medication management improving your treatment outcomes for this client? Please don't leave this blank. We need this information to determine scope of practice and assign the case. Any information you provide is greatly valued.

Your information will be encrypted.

Medication Referral Form

Family Psychological Services