Providers - Welcome to My Practice

Please use the following form to communicate clinical updates, questions or concerns and I will review it shortly.

Date*
MM slash DD slash YYYY
Please describe the purpose of this communication:
- Care coordination, enhanced communication
- Questions about appropriateness of referral
- Notification as to change in level of care
- Termination/Transition Planning
Re: Patient Initials, DOB
Initial(s) DOB
Therapist/Provider Name*
First Last Title
Therapist/Provider Email and/or Telephone*
Please detail your questions, concerns or information important for me to know:
Do you have any additional information that would be helpful for me to know such your time away, coverage staff or any transition in care ?
Please describe the working diagnosis, symptoms, issues that are the target of therapy
For providers new to working with me, please help me get to know your practice better! Briefly describe your area(s) of expertise, days/hours, referral preferences (if any)
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