Provider Referral Form Referring Provider's Name* First Last Provider's Phone*ExtensionOrganization* Patient Name* First Last Patient Date of Birth* MM slash DD slash YYYY 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*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* 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 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).