For Healthcare Providers
Provider Referral Form
Print the form below and fax or email the completed copy to (606) 229-7266 or [email protected].
RISE ABOVE MENTAL & BEHAVIORAL HEALTH, PLLC
Mental Health Services • Kentucky
Michael Sturgill, PMHNP-C | Homer Couch, PMHNP-BC
Psychiatric Referral Form
Referring Provider Information
Provider Name
Credentials / Specialty
Practice / Organization
NPI Number
Phone
Fax
Address / City, State, ZIP
Patient Information
Patient Full Name
Date of Birth
Sex / Gender
Phone Number
Email Address
Home Address
Insurance / Payor
Member ID
Reason for Referral
Primary Concern(s) — check all that apply:
Depression / Low Mood
Insomnia / Sleep Disorder
Anxiety / Panic
Substance Use / Dual Diagnosis
Bipolar Disorder
Eating Disorder
ADHD / Attention Issues
Personality Disorder
PTSD / Trauma
Autism Spectrum
Psychosis / Schizophrenia
Behavioral Issues (pediatric)
OCD
Medication Management / 2nd Opinion
Presenting Symptoms / Clinical Summary:
Current Medications:
Safety Screening
| Question | YES | NO |
|---|---|---|
| Current suicidal ideation or plan? | ||
| Current homicidal ideation? | ||
| Recent self-harm behavior? | ||
| Recent psychiatric hospitalization? | ||
| Active substance use? |
Additional Notes / Special Considerations
Documents Enclosed:
Progress / Visit Note
Previous Psych Records
Lab Results
Medication List
Prior Authorization
Copy of Insurance
Imaging / Other
Referring Provider Signature
Signature:
Date:
How to Submit This Referral
Fax to: (606) 229-7266 | Email: [email protected] | www.riseabovekybh.com
Print the form, complete it by hand, and fax the signed copy to (606) 229-7266.