Professional Referral Form

For therapists, physicians, advanced practice providers, and other healthcare professionals referring an adult patient or client to Good Enough PMHNP.

Important: This form is not monitored for emergencies. If the patient or client is experiencing a psychiatric or medical emergency, please call 911 or 988, or have the patient or client go to the nearest emergency department.

Client Information

First name

Last name

Date of birth

Parent or Guardian

Full name

Relationship to client

Contact Information

Phone number

Email address

Address

Referral Source

Full name

Phone number

Email address

Role or relationship to client

Practice or organization name

Reason for Referral

Reason for referral

Tell us what the client is looking for, and what you'd like us to help with.

How soon are you hoping I can see the patient or client?

As soon as possible Within a few weeks No particular timeframe

Supporting Documents

Attach any relevant documents, such as assessments, reports or signed releases.

Supporting documents

Add file

Please upload a file

Additional Information

Additional comments

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