Client referral form

Dr. Raymond Rogers

Date of referral

Referring provider name

Agency

Phone

Patient information

First name

Last name

Address

Primary phone

Secondary phone

Social security #

Date of birth

Sex

Marital status

Single Married Divorced Widowed

Is person being referred a minor?

Yes No

Parent/guardian name

Parent/guardian phone number

Payment information

Medical assistance (e.g., Medicare or Medicaid) Private insurance Self pay

Name of policy holder

Name of insurance

Policy # or MA #

Group # or ID #

Clinical information

Reason for referral

Diagnosis

Primary mental health diagnosis

Secondary mental health diagnosis

Relevant medical diagnoses

Relevant social factors

Mental health history

History of violence?

Yes No

Please provide details

History of suicide attempts?

Yes No

Please provide details

History of psychiatric hospitalizations?

Yes No

Dates

Previous symptoms and diagnoses

Current mental health treatment and history

Current symptoms

Current suicidal/homicidal thoughts?

Yes No

Please provide details

Current psychiatric medications (name and dose)

Primary care physician

Phone number

Additional contact (therapist, case worker, etc.)

Phone number

Additional contact (therapist, case worker, etc.)

Phone number

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Dr. Raymond Rogers

Registered Psychologist

Raymond Rogers has been practicing for more than 20 years, specializing in family and couples therapy. He has a warm, approachable style that provides a safe, comfortable environment conducive to introspective conversation and mutual listening. Dr. Rogers welcomes clients of all ages and backgrounds.

+1-613-555-0122
RaymondRogers
RaymondRogers
RaymondRogers
129 Loretta Ave N , Ottawa, ON, K1Y 2J7, CA