This form should be completed by the clinician who has a thorough knowledge of the patient's current clinical presentation and his/her treatment history.In addition to this form, please remember to fax the following information to *** or email to Interventional.Psychiatry@cchmc.org

• Patient's most recent visit note
• Patient’s treatment and medication history
• PAST and CURRENT Medications: (doses, frequency, efficacy, and side effects)
• PAST and CURRENT psychotherapies
• Patient’s primary and secondary insurance information

* fields are required

*Requesting Evaluation for (select all that apply):

Referring Provider

Patient Information

Mailing Address

Reason for Request