Northwell Referral Form

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

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Market

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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

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)

Preferred Location

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)

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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, 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.