Collaborative Care Consult Form
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Department of Psychiatry
Washington University Child Psychiatry Consult Referral Form
Please Complete this Form and Send via Fax to 314-286-1799
Service/Clinician Requested: □ Any W.U Child Psychiatrist
(Check all that apply) □ A specific W.U. Child Psychiatrist
Name: __________________
Unless otherwise specified, if the psychiatrist you request is not available we may schedule your patient with another psychiatrist in our clinic.
This referral form is for enhanced outpatient psychiatric consultation (1-4 visits to include evaluation, diagnosis and treatment/stabilization if appropriate). If at any time during the consultation process we determine that your patient requires ongoing/chronic psychiatric follow up care, we will contact you and discuss alternate referral options, including the possibility of follow up in our clinic; however keep in mind that the latter is not routinely available.
☐I agree to resume the medical management of mental health condition, if deemed appropriate (please fill out form on next page).
☐I do not agree to resume medical management of mental health conditions, please contact me to discuss alternative mental health referrals for chronic care.
Name:______________________________Phone #:_________________________
Consult Referral Form
|Patient Name: |Date of Birth: |
|Patient Phone #: |Alternate Patient Phone #: |
|Patient Health Insurance: |
|Reason for seeking psychiatric consultation (eg “diagnostic clarification” or “treatment recommendations”). |
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|Has the child been evaluated by other mental health specialists? (eg counselor, therapist, psychologist or psychiatrist; please include |
|information about both outpatient and inpatient mental health care) |
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|If the child has been evaluated by other mental health professionals, please indicate why you feel additional psychiatric consultation is needed |
|at this time (eg therapy hasn’t helped and you suspect medications are needed, you or the patient/family is not satisfied with current care and |
|want a second opinion, etc). |
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|Is anyone else currently providing treatment for this child? (Please include current and past psychotropic medication trials, other medical |
|specialists involved in care, eg cardiology, neurology, etc) |
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|Relevant History (current psychiatric symptoms, prior psychiatric evaluations, ongoing medical problems, social history, changes in school or |
|home functioning): |
|Has the primary care provider discussed mental health referral with family, and is the family willing to participate in psychiatric evaluation |
|and/or treatment? |
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|Please describe patient’s level of impairment: |
|Rating: (Low) 1 2 3 4 5 (High) |
|Please include ability to function at home & school, as well as any concerns about safety: |
| |
|Name of Referring Physician: |
|Fax# for Referring Physician: |Contact # for Referring Physician: |
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Please include demographic & insurance information sheet with this referral form
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