Telehealth (TMS and Psychological Testing available in-person ONLY):

In-Person Preferred

Telehealth Preferred

Note: A client may need to see a provider in-person based on individual treatment plans and circumstances, regardless of preference.

Referring Provider Information:

Referring Organization Name

Referring Provider Name

Specialty

Office Phone

Clinical Confirmation Email

Client Demographics(can send Client Face Sheet In lieu of this section)

Client First Name

Middle

Last

Date of Birth

Gender

Contact Phone

Contact Email

Address Line 1:

Address Line 2:

City

State

Zip Code

Insurance Information:

Insurance

Self-Pay

If TMS, the client interested in self-pay if insurance does not approve the treatment

Yes

Primary Insurance Company:

Primary Insured:

Patient Relationship to Primary Insured:

Subscriber ID:

Group No:

Secondary Insurance Company, if applicable:

Subscriber ID:

Group No:

Important notice: This message is for the use of the person or entity to whom it is addressed and may contain information that Privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or The employee or agent responsible for delivering it to the intended recipient, you are not informed of any dissemination, distribution or copying of it. This information is strictly prohibited. If you have received this message in error, please notify us immediately and destroy the related Message

Clinical Information

Diagnosis (list confirmed if known, if not list suspected)

Primary Psychiatric Diagnosis:

Secondary Psychiatric Diagnoses:

Relevant Medical Diagnoses:

Relevant Social Factors:

Current Psychiatric Treatment and History

Current suicidal/homicidal thoughts?

Yes

Does client have a current mental health provider?

Yes

If Yes, provider(s) Information

Additional Information

Please Attach the Following Documentation as Available:

Current Medication List

Psychiatric Medication History (Dates, Doses, Reasons for Discontinuation)

Recent PHQ-9/GAD-7/other recent psychiatric scale

Most Recent Clinical Note

Additional Documents

SALEM

Phone Number

Hours of Operation

PORTLAND

Phone Number

Hours of Operation

BEND

Phone Number

Hours of Operation

Client Referral Form

Clinical Information

Services

Quick Links

Other Links