Referring Provider Information

Referring Provider Name

Clinic/Hospital/Practice Name

Phone Number

Your FAX

Email Address

Patient Information

Full Name

Date of Birth

Phone Number

Email Address

Insurance Provider

Member/Policy Number

Services Requested (Check all that apply)

Member/Policy Number
TMSSpravatoQEEG-Brain Mapping3x4 lifestyle Genetic TestingBurnout Adrenal Fatigue TestingMedication ManagementPsychotherapyPsychiatric assessment

Reason for Referral

Member/Policy Number

Clinical Notes / Supporting Documents

Please upload any relevant documentation (e.g., progress notes, diagnostics, prior treatment plans). PDFs only.

Preferred Location (if applicable)

Silver LakeMount VernonTelehealth

Authorization

By submitting this referral, I confirm that the patient has been informed of this referral and has consented to the release of necessary information to Shifa Health.

Signature (Type your name to use as digital signature)

Date

Upload (recent notes, PHQ-9/GAD-7, med list), with HIPAA notice

We confirm within 1 business day; schedule within 7–10 days.