Behavioral Health Referral Form

Important:

• Handwritten forms not accepted.

• To print, use the Print button at the bottom of the form, and then fax it to the provided number.

499 Gloster Creek Village, Suite D1
Tupelo, MS 38801
p: 662-690-8007 • f: 662-842-4653

60021 Monroe St
Smithville, MS 38870
p: 662-651-4637 • f: 662-651-4636

Behavioral Health Referral

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Referring Provider Info

Date of referral (mm/dd/yy): Use mm/dd/yy

Office/Practice:

Provider:

Address:

City, State, Zip:

Phone (with area code): Must include area code.

Fax (with area code): Must include area code.

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Patient Info

Last name:

First name:

Date of birth (mm/dd/yy): Use mm/dd/yy

Age:

Phone (with area code): Must include area code.

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Reason for Referral

Patient referred for: (select all that apply):

Medication management Counseling

Preferred location:

Tupelo (f: 662-842-4653) Smithville (f: 662-651-4636)

Urgency:

ASAP 2-3 weeks 1-3 months

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The following is required before an appointment is scheduled.

• Patient demographics
• Copy of insurance card(s)
• Current med list
• Allergy list
• Office notes indicating reason for referral

FAX THIS FORM AND REQUIRED DOCUMENTATION TO [select a location above].

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