Provider Referral Form Referring Provider's Name* First Last Provider's Phone*ExtensionOrganization*Patient Name* First Last Patient Date of Birth* Date Format: MM slash DD slash YYYY Gender/PronounPatient Phone*Patient Email* We will use email to confirm we have received the referral. Treatment is not guaranteed. Patient AddressContact name (if different from patient)Contact RelationPatient's Insurance Provider*No InsuranceAetnaBlue Cross Blue Shield/Regence/HMABeacon HealthCignaFirst Choice Health/Kaiser Added ChoiceMHN/HealthnetModaOptum/United Behavioral Health/UMRProvidencePacific SourceProvidence Preferred PPOOregon Health PlanOtherInsurance Identification Number*Name of Subscriber*Subscriber's Date of Birth* Date Format: MM slash DD slash YYYY 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 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. 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 additional information regarding this patient. Chart notes can be submitted via fax to our Intake Coordinator at (503)-454-0763. For questions regarding referrals please reach out to our Intake Coordinator by phone at (503)-427-2394 (press 6).