Provider Referral Form – Northwest ADHD

Referring Provider's Name*

First Last

Provider's Phone*

Extension

Organization*

Patient Name*

First Last

Patient Date of Birth*

Gender/Pronoun

Patient Phone*

Patient Email*

We will use email to confirm we have received the referral. Treatment is not guaranteed.

Patient Address

Contact name (if different from patient)

Contact Relation

Patient's Insurance Provider*

Insurance Identification Number*

Name of Subscriber*

Subscriber's Date of Birth*

At which office would this patient prefer to access services?

East Portland
West Portland
Downtown Portland

What services are you referring this patient for (please check all that apply):*

ADHD Evaluation with therapist
Medication Management*

Services outside of an evaluation will be determined on a case by case basis after an evaluation has been completed. Evaluation does not guarantee further services. *Patients on stable medication regimens only.

Has this patient been diagnosed with anything mental health related? If yes, please list all mental health diagnosis and when diagnosis was given:*

Has this patient been diagnosed with an eating disorder? If yes, please provide the name of the disorder, diagnosis date, and current status of care i.e active problem, well maintained, in remission etc.*

Patients diagnosed with an eating disorder will need a cross referral from found here.

Please provide any clinically relevant information regarding this patient in the field below or by faxing, at a minimum, the most recent encounter note. Fax all information to our Intake Coordinator at (503)-454-0763. For questions please reach out to our Intake Coordinator by phone at (503)-427-2394 (option 6).