Zama Referral - SOL Mental Health

ZAMA Referral Form

This form is for referrals through Zama. 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

Region(Required)

Referring Clinic / Organization

Referring Clinician

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)

Permanent Street Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Clinical Information

Clinical services requested:(Required)

Therapist

Psychiatric Provider

What are you / what is the student seeking help with? Select all that apply:(Required)

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Services Requested:

Therapy

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Services Requested:

Medication

SOL 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.

UTA Athletics College Consent(Required)

I Authorize Sol Mental Health to Use or Disclose Protected Health Information as outlined in the Athletics College Consent Form available below (including mental health information and alcohol/drug treatment and prevention information. For emergency purposes only)

UTA Athletics College Consent Form

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.