Magnolia Referrals

Patient Name *

First Name

Last Name

Patient DOB *

MM

DD

YYYY

Patient relationship status *

Married

In relationship and cohabitating with partner

In relationship and not cohabitating with partner

Single and living alone with absent or minimal family/social support

Single and living alone with adequate family/social support

Single and cohabitating with family/friends/roomates

Patient Phone *

(###)

###

####

What resources is your patient open to engage with or learn more about? (choose all that apply) *

Counseling/Psychotherapy

Psychiatry referral for evaluation & medication treatment/management

Peer-led Support groups

Therapeutic Group Therapy

Specialized treatment options for specific chronic/severe issues (substance use recovery, eating disorder recovery, Bipolar disorder, Schizophrenia, OCD, ADHD)

Has your patient endorsed, either within an assessment or verbally and directly to you or verbally to their partner/support person whom is reporting this directly to you, any suicidal ideation/thoughts of self-harm? *

Yes

No

Is your patient currently involved in any legal proceedings of any kind? [including but not limited to custody hearings, divorce, criminal trial, etc.] *

Yes

No

Unsure

Is your patient a current victim of domestic abuse/violence? *

Yes

No

Suspected

Patient insurance plan? *

Uninsured

Medicaid/Medicare Plan

Aetna

Oscar Health

United Healthcare

Oxford

Cigna

Florida Blue or BCBS Plans

Humana Health of Florida

Golden Rule

Sunshine Health

Molina Healthcare

Other

Type of insurance coverage? *

PPO

HMO

Unsure

I attest that my patient has been made aware of my intent to submit this referral and has consented to being contacted by your practice via text/phone call/email. *

Yes