External Psychiatric Referral


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: 

Physical Address:

Mailing Address:      

Interpreter Needed:

     If interpreter needed, please specify:

Insurance Coverage:

     If Commercial Insurance, enter name of Commercial Insurance:

Appointment Confirmation Method: 

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? 

     If by email:

Emergency Contact's Name:

Emergency Contact's Phone:


Before referring to psychiatric services, discuss psychiatric UA policy:

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

     ROI for PCP:

     ROI for Hospital (if prior psychiatric hospitalization):

     ROI for other prescriber (if applicable):


Name of PCP or other provider:

Length in therapy:

Diagnoses:

Is the client pregnant? 

     If yes:

          Due date:

          Name of OBGYN provider:

Has the client given birth in the past 12 months?

     If yes:

          Date of delivery:

          Name of OBGYN provider:

Is the client breastfeeding?

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:

Leave this empty:

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Signature Certificate
Document name: External Psychiatric Referral
lock iconUnique Document ID: 29520274fd3cb40fe88881d23991be37e7e3d66e
Timestamp Audit
April 13, 2022 12:44 pm PDTExternal Psychiatric Referral Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
April 25, 2022 10:12 am PDTCFD Referral - referral@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
May 2, 2022 12:02 pm PDTCFD Referral - referral@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202