Stonehaven Psych Care: Referral Form

Clinical Referral

Please complete this form and a member from our clinical staff will reach out to the specified patient regarding your inquiry for an appointment Since provider clinical skills, schedules, and insurance coverage vary, this form assists in the process to determine whether a provider is a good fit for the needs of each unique patient. If the patient is currently experiencing a medical or psychiatric emergency (for example: suicidal or homicidal ideation, medication adverse effects) please seek immediate medical attention by calling 911 or going to your nearest emergency room.

Patient's First Name

Patient's Last Name

Patient's Preferred Pronouns

Patient's Gender

Patient's Date of Birth

Patient's Phone Number

Patient's Email Address

Patient's Residential Address

How did you hear about us?

Please provide the reason for this inquiry or referral.

Is the patient currently prescribed any psychiatric medications? If yes, please specify the name. If unknown, please write unknown.

If you know the patient's insurance plan, please specify the policy ID number:

For Out-of-Pocket/Self-Pay, enter "N/A"

Full name of Referrer or person completing this form:

Referrer's email:

Referrer's fax number:

Referrer's affiliated organization:

Referrer's phone number:

If there are pertinent documents, please upload them here. This portal is HIPAA and Business Associate Agreement compliant.

Add file

Please upload a file

The person completing this form consents to the collection and processing of the specified and provided information above, in compliance with company privacy policy and federal regulations. The information provided in this form will solely be used for the purpose of mental health care services. Additionally, any information provided in this form will not be shared with any entities, such as third party organizations. The person completing this form has the right to revoke their consent at any time by contacting Stonehaven Psych Care PLLC via phone or email.

Your information will be encrypted.