Provider Referral Form

Provider Referral Form — Discher and Associates, Life Center

Patient referral form

Mental health & behavioral health services · Fields marked * are required

Patient information

First name *

Last name *

Date of birth *

Sex assigned at birth

Phone number *

Email address

Address

Preferred language

Preferred contact method

Insurance & billing (optional)

Primary insurance

Member ID

Group number

Insurance phone

Secondary insurance (if applicable)

Patient is self-pay / uninsured

Reason for referral & clinical information

Primary reason for referral *

ICD-10 diagnosis code(s)

Clinical notes / additional context

Patient has active safety concerns (suicidal ideation, self-harm, or harm to others)

Patient has prior mental health treatment history

Patient is currently on psychiatric medications

Urgency level

How soon does this patient need to be seen? *

Please select an urgency level.

Referring provider

Provider name *

Credentials / title

Practice / clinic name *

NPI number

Phone *

Fax

Records / notes will be sent with this referral

Patient has been informed of this referral and consents to treatment

Date of referral *

✓ Referral submitted successfully. Discher & Associates, Life Center will be in touch with the patient shortly.