E-Referral Form for Individual Therapy

Please correct the errors described below.

Patient Demographic Information

Please note: For patient safety and effective care provision, Think Recovery DOES NOT accept patients with acute safety/suicidality concerns, active substance abuse, active psychotic disorders, or active mania. Think Recovery only provides virtual mental health services at this time for adults (age 18+). Medication prescriptions are not provided through this clinic, solely virtual therapy services are provided by licensed professionals. Individual therapy involves a 1-4 appointment initial assessment phase to determine the suitability for psychotherapy and appropriateness of fit for our specialized therapy services prior to commencing a treating relationship. 24 biweekly session limit unless otherwise discussed.

Referring Physician or NP Information

Relevant Patient History

Please list relevant medications, hospitalizations, therapy, residential treatment, detox, etc.

Reason for Referral

Ex. What is it that they identify as their issue(s) that they are motivated to work through and change with the assistance of intensive, biweekly therapy?
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