1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

External Psychiatric Referral

Name:     Date of Birth:

Preferred Name:     Preferred Pronouns:

Phone:      OK to ID:  YesNo

Physical Address:

Mailing Address:       OK to send mail?

Interpreter Needed: YesNo

     If interpreter needed, please specify:

Insurance Coverage:  None OHP Commercial Insurance

     If Commercial Insurance, enter name of Commercial Insurance:

Appointment Confirmation Method:  CallTextEmailNone

Sometimes your therapist may want to send information to you; would you prefer to have information sent to you in the mail or by email?  MailEmail

     If by email: EncryptedUnsecure

Emergency Contact's Name:

Emergency Contact's Phone:

Before referring to psychiatric services, discuss psychiatric UA policy:  Individual is agreeable to UA requirement

Please verify for completeness, or click link to complete with client:

     ROI for Medical: Completed

     ROI for Hospital (if prior psychiatric hospitalization): CompletedNot needed

     ROI for other prescriber (if applicable): CompletedNot needed

Name of PCP or other provider:

Length in therapy:

Diagnoses:

Is the client pregnant? YesNo

     If yes:

          Due date:

          Name of OBGYN provider:

Has the client given birth in the past 12 months? YesNo

     If yes:

          Date of delivery:

          Name of OBGYN provider:

Is the client breastfeeding? YesNo

Reason for referral:

Desired outcome:

Active symptoms:

Substance use:

History of psychiatric hospitalization:

History of suicide attempts:

Current of past violent thoughts or behaviors:

Relevant information for the psychiatric provider to know before meeting with the individual: