Outpatient Referral Form
Aura ID
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Biological Sex
*
Please Select
Female
Male
Is the Client a Minor?
*
Yes
No
Legal Guardian Name
Legal Guardian Phone
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone Number
*
Please enter a valid phone number.
Client Email
example@example.com
Insurance Coverage
*
Insurance ID#
*
Presenting Issue (briefly describe the reason for seeking services)
*
Services requested
*
Counseling
Med Management
Counseling and Med Management
TMS (Tempe location only)
Do you have a major depressive diagnosis?
*
Yes
No
Have you tried talk therapy before?
*
Yes
No
Was talk therapy enough to get rid of your depression?
*
Yes
No
Have you tried any of the medications listed below to help with your depression?
*
Yes
No
(SSRIs) include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), fluvoxamine CR (Luvox CR), paroxetine (Paxil), paroxetine CR (Paxil CR), sertraline (Zoloft). (SNRI's) desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor), venlafaxine XR (Effexor XR), milnacipran (Savella), and levomilnacipran (Fetzima), (TCA's) amitriptyline (Elavil), desipramine (Norpramin), doxepine (Sinequan), Imipramine (Tofranil), nortriptyline (Pamelor), amoxapine, clomipramine (Anafranil), maprotiline (Ludiomil), trimipramine (Surmontil), and protriptyline (Vivactil).
Did you do the maximum dose for at least 6 weeks or did you have a side effect that prevented you from taking it for 6 weeks?
*
Yes
No
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling down, depressed, or hopeless
*
Not at all
More than half days
Some days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
*
Not at all
More than half days
Some days
Nearly every day
Feeling tired or having little energy
*
Not at all
More than half days
Some days
Nearly every day
Poor appetite or overeating
*
Not at all
More than half days
Some days
Nearly every day
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
*
Not at all
More than half days
Some days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
More than half days
Some days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual.
*
Not at all
More than half days
Some days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
*
Not at all
More than half days
Some days
Nearly every day
PHQ9 Score
Preferred Location
*
Estrella Clinic
Gilbert Clinic
Tempe Clinic
If special accommodations are required for services, please explain:
(Interpretation services, transportation, hearing or visual impairments, etc)
Status
New
Staff
Aura URL
Aura Status
Source
Auth
Submit
Should be Empty: