Lifespan is a local provider of psychiatric & mental health evaluations and medication management services.

Thank you for choosing to partner with Lifespan Collaborative Services. To refer a patient, please complete the referral form below. You may also download & submit the PDF version accordingly and fax to 203-517-0058.

REFERRAL FORM

Synopsis of reason for med management referral

Short summary explanation of the reason the referral is being initiated-symptoms, how long in treatment with you and treatment goals etc

Medications currently prescribed and by whom?

If medications are currently being prescribed for the condition the person is being referred for, what are the medications and who is currently prescribing them?

Patient Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

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OPT In for SMS Text Messaging

By clicking "Yes" you agree to opt-in to receive SMS text messaging from Lifespan Collaborative Services

Yes

Parent/Guardian Name

If the patient is under the age of 18 years old, please provide the name of the parent or guardian.

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Insurance Info

Provide the following patient information: Insurance Company - Group ID - Member ID.

Referring Provider

Enter the name of the provider that referred you to us.

Referring Provider's Phone Number

Enter the phone number for the referring provider.

(###)

###

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Referring Provider's Email

Enter the email address for the referring provider.

Release of information completed

Was a release of information completed for Lifespan Collaborative Services to communicate with the referring provider