Provider Referral Form - Renewed Outlook

Questions or Concerns?

If you have any questions about the referral process or are unsure whether a patient may be a good fit for our practice, please call or text us at 724-302-5969 or email renewedoutlook@therapysecure.com.

Collaboration & Practice Overview

Thank you for considering Renewed Outlook Holistic Mental Health & Wellness as a potential referral option for your patient/client. We value interdisciplinary collaboration and appreciate the opportunity to review referrals that may align with our scope of services.

The information below is intended to clarify our practice model, areas of focus, and referral considerations. Reviewing this information can help determine whether our setting is likely to meet the patient’s needs. If you are unsure whether a referral is appropriate, you are still welcome to submit it for review.

Referral Scope & Fit

This practice:

Provides psychiatric evaluation and medication management with a conservative, safety-focused prescribing approach
Incorporates brief psychotherapy interventions when clinically appropriate; these services are not intended to replace ongoing psychotherapy with a therapist
Emphasizes collaborative care, diagnostic clarification when needed, and active patient participation
Provides care primarily through telehealth, with limited in-person services
Generally accepts patients age 12 and older. All pediatric referrals are reviewed on a case-by-case basis.

Additional prescribing considerations:

Controlled substances are prescribed conservatively and only when clinically appropriate. An evaluation does not guarantee that a stimulant, benzodiazepine, or other controlled substance will be prescribed. Periodic in-person visits, urine drug screening, or other monitoring may be required based on clinical circumstances, practice policy, insurance or pharmacy requirements, or applicable state or federal regulations.

This practice does not provide:

Treatment for active substance use disorders requiring specialized SUD treatment
Medication-assisted treatment with Suboxone, methadone, Vivitrol, or similar medications
Treatment for active eating disorders other than binge eating disorder
Care for primary psychotic disorders requiring a level of monitoring, staffing, or support beyond what can safely be provided in a small outpatient private practice
Injectable antipsychotic treatment
Psychotherapy-only services in most cases
One-time disability evaluations or disability/form-completion services for individuals who are not established patients

Our goal is to help ensure that patients are referred to a setting where their needs can be safely and appropriately met. Some individuals may be better served by a larger or more intensive behavioral health program.

In-Person and Virtual Service Locations

Erie, PA — limited in-person availability, generally twice per month
Kittanning, PA — limited in-person availability; this office will be closing in early 2027
Pittsburgh Area — a new in-person location is anticipated in late winter or early spring 2027
Virtual visits — available throughout Pennsylvania when clinically appropriate

Patient Demographic Information

Patient First Name:

Patient Last Name:

Patient Preferred Name:

Patient Date of Birth:

Patient and/or Parent / Guardian Phone #:

Patient and/or Parent/Guardian Email (if available):

Parent / Guardian Name (if applicable):

Insurance Considerations

Renewed Outlook is unable to accept patients with Medicare, Medicare Advantage, or Medicaid coverage, including when these are secondary or prescription-only plans.
We are not currently accepting new patients with Cigna.
We make every reasonable effort to verify insurance eligibility and network status prior to scheduling.

Primary Insurance ID# (if available):

Referring Provider Information

Referring Provider Name:

Practice / Facility:

Phone #:

Fax #:

Email:

Clinical Information
Please provide the following information to the best of your knowledge. Not all fields are required in order to submit a referral.

Primary concerns prompting referral:

Current patient medications (write "none" or "N/A" if not applicable):

Known psychiatric diagnoses (if available):

Relevant medical conditions (if applicable):

If patient is currently in therapy, please indicate type and approximate frequency (if known):

Therapist or therapy practice name (if known):

Therapist phone # (if known):

To the best of your knowledge, are there any current or recent safety or stability concerns that may affect the patient’s appropriateness for routine outpatient psychiatric care? (Select all that apply.)

No known concerns

Suicidal ideation or recent suicide attempt

Recent psychiatric hospitalization

Active psychosis

Severe or persistent mental illness requiring case management or additional support

Active substance use disorder requiring specialized treatment

Other significant safety or stability concern

Unknown

If applicable, please briefly describe the concern and approximate timing:

To the best of your knowledge, is the patient currently prescribed any controlled substances? Choose all that apply.

Stimulants (e.g. Adderall, Concerta, Ritalin, Vyvanse, etc.)

Benzodiazepines (e.g. Xanax, Ativan, Klonopin, etc.)

Sedative-hypnotics (e.g. Ambien, Lunesta, etc.)

Opioids (e.g. Percocet, Oxycontin, Vicodin, etc.)

Other

None

Additional Provider Comments (optional):

Thank you for your referral and for the opportunity to collaborate in your patient’s care. Our team will carefully review the information provided to determine whether our services are an appropriate fit.

If we are unable to meet the patient’s needs, we will follow up with you directly using the contact information provided. If the referral is a good fit, we will notify you and reach out to the patient to coordinate next steps, including scheduling and any additional information needed to support a smooth transition into care.

Your information will be encrypted.