The New School – Patient Referral

New School Office Referral Form

This form is for healthcare professionals. If you have questions about The New School referrals, please contact us at (929) 345-1915. If you are a mental health professional looking for our general referral form, please click here.

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Market (lead_source)

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Referral Type

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retURL

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OID

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Inquiry Date

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Exactius

Referral Information

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Region

Referring Clinic / Organization(Required)

Referring Clinician(Required)

Patient Information

Patient's First Name(Required)

Patient's Last Name(Required)

Patient's Phone Number(Required)

Patient's Email(Required)

Patient's Date of Birth(Required)

Preferred Location

Visit Preference

Is patient under the age of 18?(Required)

Yes

Name of Legal Guardian (if patient is a minor)

Clinical Information

Clinical services requested:(Required)

Therapist

Psychiatric Provider

What is the patient seeking help with? Select all that apply:(Required)

Please provide a reason for the referral:(Required)

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Services Requested:

Therapy

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Services Requested:

Medication

Consent(Required)

Patient has provided consent to be contacted by SOL Mental Health by phone, text, and/or email for the purpose of scheduling and/or follow up of behavioral health appointment.

SOL Mental Health adheres to HIPAA compliance and safeguards your personal information. However, we are not responsible for cyberattacks or interference. If you are experiencing an emergency, please dial 911 or visit this page for more resources.