Patient Referral Form

Refer your patients to SOL Mental Health for comprehensive psychiatric and therapeutic care. Our team will coordinate directly with you and your patient.

Referring Provider Information

Full Name *

Title/Credentials *

Organization/Practice *

Email *

Phone *

NPI Number

Patient Information

First Name *

Last Name *

Date of Birth *

Phone *

Insurance Provider

Member ID

Referral Details

Urgency Level *

Urgent (1-3 days)

Patient needs immediate attention

Routine (1-2 weeks)

Standard referral timeline

Type of Care Needed *

Primary Concerns (Select all that apply) *

AnxietyDepressionADHDBipolar DisorderPTSD/TraumaSubstance UseSleep DisordersEating DisordersPsychosisSuicidal IdeationSelf-HarmOther

Visit Preference

Clinical Notes & Reason for Referral *

Include relevant diagnoses, current medications, previous treatments, and any safety concerns.

I will send supporting documents separately

Medical records, lab results, or other relevant documents can be faxed to (555) 123-4567 or emailed to referrals@solmentalhealth.com

Consent & Authorization

By submitting this referral, I confirm that I have obtained appropriate consent from the patient to share their protected health information with SOL Mental Health for the purpose of coordinating their mental health care. I understand that SOL Mental Health will contact the patient directly to schedule an appointment and may communicate with me regarding the patient's care as appropriate.