RAO Community Health Referral Form Patients Name * First Name Last Name Patient's Email * Patient's Phone (###) ### #### What services are you interested in? Therapy Case Management/Peer Support Life Coaching Community Based Program Psychiatric Evaluation Psychiatric Follow Up Medication Managment What symptoms is the patient currently having? Last date of hospitalization? Last PCP Visit? Option 1 Option 2 Provide relevant medical/mental health diagnosis and history * What therapist is the facility/patient requesting? What treatment is being requested? Psychiatric Evaluation Medication Management/Follow Up Therapy Case Management/Peer Support Patients PCP Name , Phone Number, address Insurance Provider Medicare Medicaid Private Insurance Payor Insurance Provider, Policy Number, Group Number, Subscriber Referrer Name First Name Last Name Referrer Email Referrer Phone (###) ### #### Thank you!
