Provider Referrals

In addition to filling out this form; Please fax all pertinent Psychiatric Evals, Progress Notes and Labs to 1-206-299-9713 We look forward to partnering with you. We will review your information, and contact you regarding our availability for accepting new patients within 48 hours. Note, submission of this form does not guarantee service, as we may be unable to take on new patients at this time.
Provider Name*
Provider Contact Info*
Provider Email*
Patient Name*
Patient Contact Info*
Brief Referral Description*
(i.e., Depression, Anxiety, PTSD, etc)
Current / Recent Medication History*
Medication / Dose / Frequency