Provider Referral Form

Please complete the patient referral form so we can ensure the referral is routed to the correct team member and followed up on appropriately. The form also allows you to indicate whether you’d like to be notified once the patient has initiated services, so we can keep you updated as requested.

Patient Information

First Name

Last Name

Preferred Name

Date of Birth * required

Gender *

Male

Female

Non-Binary

Transgender

Phone

Primary Caregiver Information

Caregiver First Name

Caregiver Last Name

Relationship

Phone

Custody Status

Custody not a concern (caregivers are married or primary caregiver has full custody)

Custody needs to be clarified (separated/divorced, shared, or unclear custody)

Preferred Contact

Reason for Referral

Spanish Speaking Family

Who should we contact? *

Primary Caregiver

Patient

Preferred Method:

Phone (voicemail ok)

Text

Check all that apply:

Individual Therapy

Individual Therapy for Family Member

Family Therapy

Psychological Assessment (ADHD and ASD)

Other

Clinical Summary or Comments

Referring Provider Information

Referring Provider Name

Phone

Referring Provider Organization

Follow-up Requested by Referring Provider

Check all that apply:

Yes — Please only confirm that the is patient connected with services.

Yes — I would like to discuss with OpenMinds intake coordinator before intake.

Yes — I would like to discuss with OpenMinds treating provider after intake.

No follow-up needed.

CONSENT: I confirm that the patient/caregiver has given verbal consent for this referral to be shared with OpenMinds Mental Health Services for follow-up.

Todays Date * required

Thanks for referring to OpenMinds! We will be in contact with the patient shortly.

OpenMinds is an approved 501(c)(3) organization: Tax ID 88-4179016

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