Adventist Referral Form - SOL Mental Health

Adventist HealthCare Referral Form

This form is for Adventist HealthCare practitioners. If you are a mental health professional looking for our general referral form, please click here.

This field is hidden when viewing the form

Market (lead_source)

This field is hidden when viewing the form

Referral Type

This field is hidden when viewing the form

retURL

This field is hidden when viewing the form

OID

This field is hidden when viewing the form

Inquiry Date

This field is hidden when viewing the form

Exactius

Referral Information

Referring Clinic / Organization(Required)

Referring Clinician(Required)

Referring Contact(Required)

Referring Phone(Required)

Referring Email(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)

This field is hidden when viewing the form

Select your region:

Preferred Location(Required)

Visit Preference(Required)

Is patient under the age of 18?(Required)

Yes

Name of Legal Guardian (if patient is a minor)

Street Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Patient's Insurance Company(Required)

Patient's Policy Number(Required)

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)

This field is hidden when viewing the form

Services Requested:

Therapy

This field is hidden when viewing the form

Services Requested:

Medication

Consent(Required)

Patient has provided consent to be contacted by SOL Mental Health by phone, SMS text message, and/or email for the purpose of scheduling and/or follow up of behavioral health appointment. Message & data rates may apply. The patient can reply STOP to opt-out of further SMS text messaging.

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.