Internal Referral Complete the form below to submit your referral. Referring Clinician First Name *Last Name *Patient contact informationFirst Name *Last NamePhone *Other Information *For referrals to IOP, clinical justification is mandatory! You must write a few sentences explaining why client needs IOP and why regular routine services are not effective. This is for insurance approvalPatient's Insurance *Service/treatment you are referring your patient to *Psychiatry (Medication Management)Individual PsychotherapyFamily TherapyCouples CounselingPrimary Mental Health - Intensive Outpatient Program (IOP) for Adults (18+) - 9 hours/week - Only accepting for commercial ins ptsKetamine IM (Intramuscular Injection) Assisted PsychotherapyTeens IOP Valencia hybridPlease note - for Triwest clients who require authorization, routine requests will be taking 3 months because of the VA. If you are referring a client with needs sooner, please submit the request as urgentReferral Priority *Urgent (should be seen ASAP)Semi-Urgent (should be seen within one week)Routine (is safe being seen after more than one week for preventative care)Internal services *Psychiatry (Medication Management)PsychotherapyIntensive Outpatient Program (IOP)/Partial Hospitalization Program (PHP) *No Medi-Cal*Ketamine Assisted PsychotherapyIf you would like the patient to receive further education on any internal services and treatments from the Referral Coordinator, please check off which onesSend Message
