UT Psychiatry Referral Form

UT Psychiatry Referral Form

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We accept patients who are not currently actively suicidal, actively wishing to hurt someone else or who are otherwise unsafe to wait for a routine outpatient appointment. If the patient is in crisis, but without safety concerns, they may call 988 for the Suicide and Crisis Lifeline. If there are safety concerns, the Mobile Crisis Unit should be called at 855-CRISIS- (1-855-274-7471), 911 or arrange safe travel to the nearest emergency room.

Please Note: We do not accept referrals for disability, forensic evaluation, workman’s comp, neuropsychological testing, couples and family therapy, and group therapy.

Patient Information

Name*

First and Last Name

Date of Birth*

Social Security Number*

Address*

City, State*

ZIP Code*

Phone Number*

Insurance Name*

Insurance ID Number *

Clinical Information

Referring Physician*

Contact Name*

Contact Phone Number*

Reason for Referral*

Select all that apply

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Please Explain Your Choice*

File Upload

Please fax Referral, Demographics, Most recent office visit note, Hospital Records, and Medication list to 901-302-2420 or upload via the space below.

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