Provider/Therapist Referral Form for New Patient Evaluation/Intake for Psychiatry

Please Note: We only see patients with a scheduled appointment at our clinic. Patients are required to pay copay and/or full payment for services at each appointment.

 Directions for Completion:
1. Please complete this entire form.
2. Attach requested additional information.
3. Please have your staff call (864) 643-0456 to let us know you will be faxing a patient referral or sending a referral through our website.
4. Fax all information to 864.844.9430 or upload required information while submitting referral through our website.