Referral Number: (920) 750-7000 Fax: (920) 882-5484 Thank you for referring your patient to Catalpa Health. Please provide the following information and pertinent clinical information so that we can provide the best and most timely service. Patient Information Referring Provider Information Patient Name: Provider Name: Parent/Guardian Name(s): Provider Address: Patient Address: Phone Number: Date of Birth: Fax Number: Phone Number: Insurance: Sub ID#: Catalpa does not provide treatment for alcohol &/or substance abuse. Please answer questions: What is the patient’s chief complaint? Severity of Problem: Mild Moderate Severe (been to ER or out of school) ⁭ ⁭ Is patient currently working with a counselor? (If yes, please provide name and agency of provider): Please indicate any history of significant medical issues: I AM REFERRING PATIENT FOR: ⁭ Counseling Psychological/Neuropsychological Testing *Medication Management (see below) MEDICATION MANAGEMENT, IF YOU ARE REFERRING FOR PLEASE INCLUDE PATIENT’S PAST AND CURRENT MEDICATIONS PRESCRIBED (Psychotropic or otherwise). *Other helpful information for any referral includes past or current evaluation/diagnosis/treatment by therapist, psychologist or psychiatrist including most recent office visit note. If your patient has not received contact from Catalpa within 1 week of referral, please encourage them to call Catalpa directly at (920)750-7000. Please note: Catalpa Health may not offer all services requested. Patient may be referred to or offered another provider/facility for required services.
Referral Number: (920) 750-7000 Fax: (920) 882-5484 Thank you for referring your patient to Catalpa Health. Please provide the following information and pertinent clinical information so that we can provide the best and most timely service. Patient Information Patient Name: Parent/Guardian Name(s): Patient Address: Date of Birth: Phone Number: Insurance: Sub ID#: Referring Provider Information Provider Name: Provider Address: Phone Number: Fax Number: Catalpa does not provide treatment for alcohol &/or substance abuse. Please answer questions: What is the patient’s chief complaint? Severity of Problem: Mild ⁭ Moderate ⁭ Severe (been to ER or out of school) Is patient currently working with a counselor? (If yes, please provide name and agency of provider): Please indicate any history of significant medical issues: I AM REFERRING PATIENT FOR: ⁭ Counseling Psychological/Neuropsychological Testing *Medication Management (see below) IF YOU ARE REFERRING FOR MEDICATION MANAGEMENT, PLEASE INCLUDE PATIENT’S PAST AND CURRENT MEDICATIONS PRESCRIBED (Psychotropic or otherwise). *Other helpful information for any referral includes past or current evaluation/diagnosis/treatment by therapist, psychologist or psychiatrist including most recent office visit note. If your patient has not received contact from Catalpa within 1 week of referral, please encourage them to call Catalpa directly at (920)750-7000. Please note: Catalpa Health may not offer all services requested. Patient may be referred to or offered another provider/facility for required services.