SalusCare Referral Form

Phone: (239) 275-3222 • Fax: (239) 275-7789
email: WelcomeCenterStaffAll@SalusCareFlorida.org

REFERRAL FORM

Please include as much information as possible on behalf of your patient this will help us expedite your request and provide them with the appropriate level of care.

SALUSCARE REFERRAL FORM
Please complete all fields and submit this form

Patient First Name

Patient Last Name

DOB (mm/dd/yyyy):

Age:

Street Address:

Phone Number(s) (include area code):

City, State & Zip

Name of parent or legal guardian.

Phone number (include area code):

REFERRAL SOURCE INFORMATION

Your Name:

Practice, Agency or Program:

Your Phone Number:

Your fax number:

HOW CAN WE HELP THE PATIENT?

Psychiatric Evaluation	Mental Health Therapy	Substance Abuse Services
Community-based services	Other:

What prompted your referral for mental health services?

INFORMATION TO INCLUDE WHEN SENDING THE REFERRAL
To better serve our mutual patients and make their first appointment more effective, please include the information listed below.

Diagnosis
Most recent related note
Medication including dosage

History
Lab results
Discharge Summary
Serious Medical Conditions:

REFERRAL COMPLETED BY: DATE:

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