Refer a Patient to Geriatric Psychiatry Clinic

How to Make Referrals

For external referrals (from providers outside of the 91�鶹��ֱ�� System): Please fill out the referral form below here or print out the referral form and fax to 801-587-3631.

For internal referrals (from providers within the 91�鶹��ֱ�� System): Please use EPIC and enter an order for “AMB Referral to Psychiatry” and select Geriatric Psychiatry Clinic.

Health professionals are also welcome to call 801-587-8007 with any patient care inquiries.

Referring Provider Information

Full Name (First, Last) ^*

Office Address

Street Address ^*

City ^*

State ^*

ZIP/Postal Code ^*

Referring Provider phone number ^*

Referring Provider fax number

Referring Provider email address ^*

Patient Information

Full Name (First, Last) ^*

U of U Health record number (if applicable)

Patient Address

Street Address ^*

City ^*

State ^*

ZIP/Postal Code ^*

Home phone number

Cell phone number

Date of Birth ^*

Age ^*

Gender ^*

Emergency Contact of Primary Caregiver name ^*

Relationship to Patient ^*

Contact phone number ^*

Patient Insurance Information

Primary Insurance

Phone Number

ID Number

Group Number

Primary Insurance holder full name

Primary Insurance holder date of birth

Clinical Information

Reason for referral

Please list all psychiatric diagnoses

Is the patient cognitively impaired or need assessment for cognitive impairment? If yes, provide details

Does the patient require a caregiver to accompany them to appointments? If yes, provide details

Does the patient have a history of violence or suicide attempts? If yes, provide details

Is the patient currently experiencing suicidal or homicidal thoughts? If yes, provide details

Relevant medical diagnoses including all chronic conditions

Medication review (Please list all current medications patient should be taking and why)

Is the patient currently being treated for alcohol or substance abuse? If so, where are they being seen?

Has the patient ever been treated for alcohol or substance abuse?

Please provide scores for the following assessments to be completed by referring physician

GAD-7

PHQ-9 or GDS

Mini-Cog

MOCA (if indicated)

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