Psychiatry Referral

Referrals to MAHEC's Department of Psychiatry

Please use this form to refer patients to MAHEC's Department of Psychiatry. Note that incomplete forms will delay appointment scheduling.
If you are experiencing a mental health crisis, please contact the RHA Mobile Crisis team at 1-888-573-1006 or call 911.

Please Note! This referral is not considered received by MAHEC until you receive a confirmation number after clicking the submit button.
Referring Source
Who is submitting this referral?*
If you are referring yourself or a family member, please select "Self/Family Member"
School*
Referring Agency*
Referring Agency Provider or Contact*
Referring Agency Phone
Please enter a valid phone number.
Referring Agency Fax
Please enter a valid phone number.
Referring Agency Email
example@example.com
Send a confirmation number to this email?

Yes

Patient Demographics
Patient Name*

Legal First NameLegal Last Name
Middle Initial
Patient Date of Birth*

MonthDayYear
Healthcare Decisions

Please check here if the patient has a legal guardian
Assigned Sex at Birth*
Pronouns
First Name Patient Goes By (if different than Legal First Name)
Race*
Ethnicity*
Primary Language*
Language Spoken at Home*
Insurance Information
Insurance
Please type in any patient insurance information. Please type "NA" if none or unknown
Contact Information
Today

MonthDayYear
Date
Patient Age
Please provide the contact information of the student as they are 18+ yrs old.
Please provide legal guardian name and contact information.
Guardian Name*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Send a confirmation number to this email?

Yes
Patient Address
Street Address*
Apt, suite, unit or floor #
City*
State*
Zip Code*
Input as 5 digits (e.g. 12345)

Referral Details
Preferred Location*
Which treatment service are you requesting?*
Which treatment service are you requesting?*
Which treatment service are you requesting?*
Which treatment service are you requesting?*
Which treatment service are you requesting?*
Requested Service
Psychiatric Evaluation / Medication Management: A psychiatrist or advanced practice provider will talk with the patient to understand their mental health. They will ask the patient about their symptoms, history, and behaviors to help figure out if they have any mental health conditions and recommend the best treatment.
Therapy: A trained therapist will help the patient talk about and work through any emotional or mental challenges they are facing. Therapy is meant to help the patient feel better, learn ways to cope with stress, and grow as a person.
Partial Hospitalization Program (PHP): Please attest to the following conditions for PHP treatment*

PHP is for patients 18+ with acute (rather than chronic) mental health condition, or acute exacerbation of symptoms and would likely need hospitalization, or to remain hospitalized, if PHP weren’t an option. The primary presenting problem is NOT substance use.The patient must demonstrate severe functional impairment in at least two domains.The patient must be able to care for basic physical needs and able to benefit and actively participate in primarily group therapy and activities 5 days/week 4 hours/day during business hours, usually for 2-3 weeks on the Biltmore campus.Patient is able/willing to begin attending within 2 business days if accepted
TMS History

Does the patient have a history of seizures?Does the patient have any metal implants in/around the head?
Previous Seizure Details*
Please provide as much detail about previous seizures as possible
Implant Details*
Please provide as much detail about the implant as possible
School*
School Field Value
Services Currently Receiving

Is the patient currently receiving services from any other mental health provider (i.e. therapy, psychiatry, collaborative care, intensive in-home services, etc.)?
Services Currently Receiving*
List any services the patient is currently receiving from any other mental health provider
Reason*

Please briefly describe the primary reason(s) that the patient is requesting services.0/3500
Attention: Please note that if the patient becomes a MAHEC client, this reason will be included in the referral that is saved to the patient’s chart.
Please attach additional patient documentation to this request form or fax to (828) 333-5465

Up to 10 files may be uploaded
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Referrals to MAHEC's Department of Psychiatry

Referring Source

Patient Demographics

Insurance Information

Contact Information

Patient Address

Referral Details