Four County Counseling Center Physician Referral |
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Please complete and fax to: 574-722-9523 |
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| Name of referring physician: |
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| Address: |
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Phone: |
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Fax: |
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PATIENT INFORMATION |
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| Name of Patient: |
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| Address: |
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City/St/Zip: |
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| Patient phone: |
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| Patient DOB: |
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| Patient Social Sec.# |
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PATIENT/GUARDIAN INFORMATION (if applicable)
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Name: |
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Address (if different from above): |
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City/St/Zip: |
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Phone: |
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Social Security # or DOB: |
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INSURANCE INFORMATION
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Ins. Company: |
/Ph#: | |||
Ins. I.D. / Policy #: |
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Pre-certification Ph. #: |
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Policyholder Name: |
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Policyholder SS#/DOB: |
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Employer: |
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SERVICE REQUESTED : |
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| Psychiatric evaluation with follow-up by Four County Counseling Center. Patient will be scheduled for an intake prior to evaluation. | ||||
| Psychiatric consultation/Recommendations for primary care physician follow-up. Psychiatrist will mail notice of recommendations to primary care physicians. No prior intake required. | ||||
| Pychological testing/Recommendations |
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REASON FOR REFERRAL (presenting problem): |
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For Four County Counseling Center Use: |
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Appointment date/time/location: |
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