Psyche PC
1120 N Lincoln St, Ste. 1601 | Denver, CO 80203
Referral Form – Outpatient Psychiatric Services
(Medication Management, TMS, and Spravato®)
Return by fax: (720) 306-5382, or email: Inquiries@PsycheDenver.com
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Patient Information
Last Name
TEST
First Name
DBM
Middle Initial
J
Birth Date
1999-01-14
Age
50
Gender
Male
Female
Non-binary
Address
123 anystreet
City
anytown
State
us
Zip
12345
Best Contact Phone Number
9998887777
Messages OK?
Text
Voice
Email Address
dev+patient@drawingboard.marketing
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Emergency Contact
Name
Jane Doe
Relation to Client
Mother
Best Contact Phone Number
8887776666
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Referring Clinician Information
First Name
Doc
Last Name
Holliday
Practice/Clinic
Best Clinic
Phone
7776665555
Fax
6665554444
Email
ops+referrer@drawingboard.marketing
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Referral Type
Referral Type (check all that apply):
Outpatient Psychiatric Medication Management
Transcranial Magnetic Stimulation (TMS)
Spravato® (esketamine) treatment
I'm unsure
Any other notes about why patient is being referred?
Not at this time
Not at this time
Clinical Information
Primary Diagnosis
TBD
TBD
Secondary/Relevant Diagnoses
Inconclusive
Inconclusive
Current Medications
Tylenol
Tylenol
Past Psychiatric Treatments/Trials
Therapy
Medications
TMS
ECT
Other
light therapy
Allergies?
Bees probably
Relevant Medical History
Only irrelevant medical history
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Supporting Documentation (attach if available):
?
Daisy-Queen.jpg
Anthony.jpg
Please upload the following types of documentation: Recent psychiatric/medical notes, Medication history, Labs, Insurance information
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Acceptance & Signature
At Psyche PC, our goal is to work in partnership with you to support your patient’s mental health needs. We evaluate each patient independently and recommend treatment options that are clinically appropriate and in the patient’s best interest—while always respecting your ongoing relationship with them. We maintain open communication, keep you updated throughout the course of care, and return the patient to your primary management once psychiatric treatment is complete. Our team values collaborative care and strives to complement the important work you’re already doing.
⚠️ Note: Completion of this form does not guarantee acceptance into treatment programs. Patients may require additional assessment to determine eligibility (especially for TMS and Spravato®).
My signature confirms that the information provided above is accurate to the best of my knowledge and may be used by Psyche PC to evaluate and contact the patient for psychiatric services.
dev+signer@drawingboard.marketing
11/14/2025, 1:56:56 PM
98.176.149.68