College Health Referral

Patient's Name

Phone

Date of Birth

State

City or Preferred Office

Insurance Provider

Member Policy #

Group #

Is the patient aware that they are being referred for mental health care? Yes No

What type of service are you requesting? Medication Management Therapy Couples/Partner Therapy Group Therapy

Reason for Referral

Referring Provider Name

Name of Practice/Group/Organization

Phone

Fax

Referral Upload (Optional)

Additional Questions or Comments

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