Referrals | My Site 1

Patient Referrals

Please take a moment to fill out the form.

Patient Full Name:

Patient Date of Birth

Patient Phone Number:

Patient Email:

Patient Insurance Carrier:

Please fax or email a copy of the patient's recent clinical notes, medication list, relevant psychiatric records, previous diagnostic assessment, ADHD rating scales or school records (if applicable), and/or relevant laboratory results.

Records may be sent by secure fax to 218-885-8840, or email to info@clearwatermentalhealthwellness.com

List all psychiatric diagnoses:

By submitting this referral, I confirm that I am authorized to share the information provided for the purpose of coordinating the patient's care and that any required patient authorization has been obtained.

Referring Provider:

Clinic/ Organization:

Phone:

Fax:

Referring Provider Signature:

Today's Date required

What Happens Next?

Once received, our team will review the referral and determine whether the requested service is appropriate and available. We may contact the patient or referring provider for additional information. Scheduling is subject to provider availability, service eligibility, and insurance verification.

Please note: Submission of a referral does not guarantee acceptance or an appointment. This form is not intended for emergencies. For an immediate safety concern or psychiatric emergency, contact 911 or go to the nearest emergency department.

Thanks for submitting!

Patient Referrals

What Happens Next?

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