Client Refferal Form

for Physicians or Medical Staff

In most cases, David M. Harris, LCSW or an associate clinician will personally contact the referral patient to conduct a brief telephone interview, assess the immediacy of the patient's need, and get the patient an appointment as soon as possible. 

 

Because of the rigorous schedule of clients seen at our practice, it is often more efficient to contact us by email, or via our form. The form below will give us the information we need to respond effectively. If this referral is urgent (e.g., suicidality, possible or confirmed domestic violence, recent trauma) please indicate this in the description area, so that we may prioritize this patient's request.

 

Thank you for entrusting us with your patient's mental health care. 

© 2011-2020 Positive By Design LLC/David M. Harris, MSW, LCSW. All Rights Reserved.

  • Twitter Clean
  • LinkedIn Clean