Request A Consultation

Please complete the following information to ensure the timely and appropriate coordination of an initial referral appointment. We will contact the patient with appointment date and time. Exclusionary Conditions: Schizophrenia, IDD, Autism

Today's Date*

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Patient Information

First Name*

Last Name*

Middle Initial*

Social Security #:*

Email*

Date of Birth:*

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Sex:*

Male
Female

Home Phone:*

Cell Phone:*

Address:*

Street Address City State ZIP Code

County of Residence:*

3rd Party Coverage

Primary Insurance Plan*

Policy Number*

Effective Date:*

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DD

YYYY

Expiration Date:*

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Benefits Plan*

Group Number*

Relationship to Patient:*

Policy Holder Name*

DOB

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Will you be using a Secondary Insurance?*

Yes
No

Secondary Insurance Plan*

Policy Number*

Effective Date:*

MM

DD

YYYY

Expiration Date:*

MM

DD

YYYY

Benefits Plan*

Group Number*

Relationship to Patient:*

Policy Holder Name*

DOB*

MM

DD

YYYY

Interpreter Needed:*

Yes
No

What Language?*

Referring Source Information

*

Primary Care Provider
Medical Group / Facility
Self

Referral Source Name*

Phone*

Referral Source Address*

Street Address Address Line 2 City State ZIP Code

Reason for Referral:*

(We do not currently manage stimulants)

Medication Management
Psychotherapy

How did you hear about us?*

Current Diagnosis(es):*

Both medical and psychiatric. Exclusionary conditions include: Schizophrenia, IDD, Autism.

Please provide narrative for the reason of the referral and current psychiatric presentation (please be specific regarding signs/symptoms):*

Send all relevant chart notes, clinical history, lab results, tests/therapy/medication history to fax # (210) 261-1837, encrypted secure email to centercare@chcsbc.org or, attach below: