Referral Order

*Services as provided by Allan J McCorkle MD, PA dba Lone Star Psychiatric Services
**Services as provided by Carewright Clinical Services

All fields must be completed in full before the referral can be processed.
(May send this referral form prior to obtaining physician signature)

Facility Name

Attending Phsysician

Patient Name

Patient Date of Birth

To evaluate and treat, via face to face and/or compliant telemedicine platform. (Must check one or both boxes)

Psychiatric Medication Management (Psychiatry)* Psychotherapy and Counseling Services (Psychology)**

Complete if POA/Responsible Party/Guardian Agrees

By checking this box typing your full legal name Above, you acknowledge that this constitutes your electronic signature and that the information provided is true and accurate

Agreed

Complete if Patients with a diagnosis of dementia or other cognitive disorder require consent from POA/Responsible Party/Guardian. Signature of Nurse obtaining verbal order from Attending Physician / TORB / VORB:

Verbal Order Signature/Witness

Attending Physician Signatures

By checking this box typing your full legal name Above, you acknowledge that this constitutes your electronic signature and that the information provided is true and accurate

Agreed

By checking this box typing your full legal name Above, you acknowledge that this constitutes your electronic signature and that the information provided is true and accurate

Agreed

Is this referral initiated by the results of a Trauma Screening?

Yes No

If yes, please upload trauma screening with referral paperwork.

Do you want this patient seen on our next scheduled visit? (Y/N)

Yes No

If no, please contact office to arrange for a prompt evaluation.

Upload the following: COMPLETED REFERRAL FORM, FACESHEET, and CURRENT WORKING/UPDATED MAR

Message

Contact@Mysite.com |
123-456-7890

Referral Order

*Services as provided by Allan J McCorkle MD, PA dba Lone Star Psychiatric Services**Services as provided by Carewright Clinical Services

All fields must be completed in full before the referral can be processed.(May send this referral form prior to obtaining physician signature)

*Services as provided by Allan J McCorkle MD, PA dba Lone Star Psychiatric Services
**Services as provided by Carewright Clinical Services

All fields must be completed in full before the referral can be processed.
(May send this referral form prior to obtaining physician signature)