Refer A Patient - Skycloud Health

Referral Form

Please read our referral criteria. This form is for Primary Care Providers and Psychotherapists. This is not a guarantee of treatment.

Referring Provider’s Name:(Required)

Provider’s Phone:(Required)

Extension:

Provider Fax:

Organization:(Required)

Patient Name:(Required)

Patient Gender/Pronouns:(Required)

Patient DOB:(Required)

Patient Email:(Required)

Patient Phone:(Required)

Patient Address:(Required)

Patient Insurance Company:(Required)

Contact Name (if different from patient):

Contact Relation:

Reason for Referral:(Required)

Please list all of the patient's mental health diagnoses:(Required)

Has this patient been hospitalized for psychiatric reasons or attempted suicide within the last 3 months?(Required)

Has this patient been diagnosed with an eating disorder or substance use disorder? Please list name of disorder and current status:(Required)

How long have you been working with this individual and how often do they see you? Have your appointments been in-office, via telehealth, or a combination?(Required)

Patient’s most recent vital signs (height, weight, BP/pulse) and date/setting taken:

Please include any clinically relevant information regarding this patient (or fax most recent encounter note to (503) 386-3293:

Thank you for taking the time to coordinate care for this patient. We will email the patient to let them know we received your referral.

Skycloud Admin

Evidence-based mental
healthcare at Skycloud

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503-694-3381

Referral Form

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