Referring Provider
Patient Information
Diagnosis / ICD-10 Code(s)
Requested Mental/Behavioral Health Services
Psychiatric Evaluation & Management
Individual Therapy
Group Therapy
Family/Marital Therapy
Medication Management
Substance Use Counseling
Other
Frequency & Duration
Risk / Safety Considerations
Any known risk of harm to self or others?
Yes
No
Referring Provider Signature
.png)