William Greenleaf Eliot Division of Child & Adolescent ...
Washington University Child Psychiatry Consult Referral Form
Please complete this Form and send pertinent medical records to Fax 314-396-8266
Service/Clinician Requested: (Check all that apply)
□ Any W.U Child Psychiatrist
□ Autism Clinical Center
□ Anxiety Clinic
□ EPIC-ITAP
□ First Contact
□ Preschool Clinic (Infancy-5 years of age)
□ Telemedicine
□ Specific W.U. Child Psychiatrist Name: ___________________
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 am willing to collaborate and resume the medical management of mental health condition, to the degree determined possible.
☐I am not willing to resume medical management of mental health conditions, please contact me to discuss alternative mental health referrals for chronic care.
If not why:
|Referring Provider Information: |
|Provider Name:______________________________________________________ |
|Provider Phone Number:______________ Provider Fax Number:_______________ |
|☐ Primary Care ☐ Specialist ☐ Other |
Referring provider Signature: __________________________ Date: ____________
|Patient Information: | |
|Patient name:_______________________________ |Insurance Carrier:___________________________ |
|Patient Date of Birth: ________________________ |Insurance ID:_______________________________ |
|Parent/Guardian Names:______________________ | |
|Phone Number:_____________________________ | |
|Alternate Number:___________________________ | |
1. Reason for seeking psychiatric consultation:_________________________________
Describe:_________________________________________________________________________________________________________________________________
2. Severity of Problem: ☐ Mild ☐ Moderate ☐ Severe (Describe) Details:__________________________________________________________________________________________________________________________________
3. Pertinent past Psychiatric/Medical History: ________________________________________________________________________________________________________________________________________
4. What is the key question you want addressed? ________________________________________________________________________________________________________________________________________
5. Has the child been evaluated by other mental health professionals? ☐ Yes ☐ No
If yes please indicate why you feel additional psychiatric consultation is needed: ________________________________________________________________________________________________________________________________________
6. Have any treatments been tried for the current problem and if so, what are they?
____________________________________________________________________
____________________________________________________________________
7. Please list prior medications and therapy trials:
____________________________________________________________________________________________________________________________________________________________________________________________________________
8. Is alcohol or substance abuse a concern? ☐ Yes ☐ No
9. Current medications patient is on: ________________________________________________________________________________________________________________________________________
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Please include demographic, insurance and guarantor information with this referral form.
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