ADULT OUTPATIENT PSYCHIATRY

REFERRAL FORM Fax Referral to (212) 305-8394

Patient Information Date: ________________

Name: _______________________________________ Date of Birth: _____________NYPH MRN#: __________________

Address: ____________________________________________________________________________Zip: _____________

Preferred Phone: ______________________________ Alternate Phone: ____________________________________

Please Indicate Dominant Language: ☐English ☐Spanish ☐Other Language: _____________________

* INSURANCE TYPE & NUMBER MUST BE PROVIDED FOR REFERRAL TO BE PROCESSED

Name of Insurance: ________________________________Policy #: ___________________________________

Patient ID # ___________________________

Referral Source- Contact information must be provided for referral to be processed

Clinician: ___________________________________ Service: _________________________________________________

Contact #: ___________________________________ Pager & Email Required: ___________________________________

If patient is being referred from inpatient setting, please attach Admission note and last 3 progress notes.

Clinical Information / Reason for Referral: _______________________________________________________________

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Does the patient have a history of psychiatric treatment? ☐Yes ☐No Location: __________________________________

Psychiatric Hospitalizations? ☐Yes ☐No #Hospitalizations: ____ Last hospitalization: ___________________________

Does the patient have any current or past safety issues?

☐None ☐Suicidal ☐Homicidal ☐Violent ☐Other safety or legal issues

If YES to any of these, please explain: _____________________________________________________________________

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Current or past psychotic symptoms? ☐Auditory hallucinations ☐Visual hallucinations ☐Paranoia ☐Other

Please explain: _______________________________________________________________________________________

Current or past substance abuse or dependence? ☐Alcohol ☐Marijuana ☐Other illicit drugs

Please describe: _______________________________________________________________________________________

Medical Providers (e.g., PCP, OB/GYN): ___________________________________________________________________

What are the patient’s current medical problems? ____________________________________________________________

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Is the patient pregnant or post partum? (if Yes, indicate delivery date)?: ___________________________________________

Please list the patient’s current psychiatric medications: _______________________________________________________

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Name and contact info of clinician prescribing these: _________________________________________________________

APC Tracking ONLY:

Dates: Received: ________________ Referrer contacted: ________________ Patient contacted:_______________

Is patient willing to learn about research options? ☐Yes ☐No

Triage priority: ____________

Appointment Date and Time: ______________________

OR Referred out to: _________________________________ (give reason): ________________________________