Referring Provider Information 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 Language Spoken EnglishSpanishYorubaRussianUrdu Services Requested (Check all that apply) Treatment Resistant DepressionSpravatoQEEG-Brain Mapping3x4 lifestyle Genetic TestingBurnout Adrenal Fatigue TestingMedication ManagementPsychotherapyPsychiatric assessment Reason for Referral 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 We confirm within 1 business day; schedule within 7–10 days.
