Client Referral Form


In most cases Dr. Kennedy will personally contact the referral patient to conduct a brief telephone intake, assess the immediacy of the patient's need, and get the patient an appointment as soon as possible. 

Because of the rigorous schedule of clients seen at our practice, it is sometimes *best* to contact Dr. Kennedy via email, and using this form will give us the information we need to respond effectively.

If this referral is urgent (e.g., suicidality, possible or confirmed domestic violence, recent trauma, pending court date) please indicate this in the description area, so that we may prioritize this patient's request.

Thank you for entrusting us with your patient's mental health care. 

Please provide the name of the referring physician and office:
(we will also use this information to update our records)

First Name
Last Name
Title
Practice Name
Street Address
Mailing Address
City
State/Province
Zip/Postal Code
Work Phone
FAX
E-mail
Practice Website?

Name and title/department name of the staff member submitting this form:

Name

Please provide the contact information for the referral patient:

First Name
Last Name
Work Phone
Home Phone
E-mail

Enter the patient's date of birth:

-- mm/dd/yyyy

Client's Social Security number if available:


Is this client a minor?

Yes No

If patient is under 18, please provide the following information on the parent or guardian:

First Name
Last Name
Street Address
contact type: Parent? Step-Parent?
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail

Please explain the reason for this referral:


Is the patient currently being prescribed any psychotropic medications? (if so please list the medication name and dose)

Please indicate below any preferences the patient has about callback times.
(e.g., don't call past 9 p.m., works 3rd shift, call anytime, etc.)

 


Kennedy Consulting.
Copyright 2006 William D. Kennedy, Psy.D.  All rights reserved.
Revised: 12/09/11