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Interventional Psychiatry Online Referral Form

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.

* fields are required

*Requesting Evaluation for (select all that apply):

Referring Provider

Patient Information

Reason for Request

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 o PAST and CURRENT Medications: (doses, frequency, efficacy, and side effects) o PAST and CURRENT psychotherapies • Patient’s primary and secondary insurance information