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Curis Mental Health
Referral Form

Please Fax Patient Demographics, Diagnostics, and Insurance Information.

First Name

Last Name

Today's Date

Chief Complaint/Diagnosis

Patient Email

Patient Phone #

Criteria For Consideration: please check all that apply:

Eating Disorder Somatization Personality Disorder Spinal Cord Stimulator Exam Hypochondriasis Anxiety Depression Substance Abuse Suicide Relationships Self Esteem Body Dysmorphia Trauma Other

If you selected other please tell us the modality/service...

Clinical Restrictions/Contradictions

Referring Physician's Name

Referring Clinic

Preferred Location

Upload Any Additional Files Needed

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