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Enlightenment Psychiatry Referral Form

⚠️ Important: This form is not intended for crisis situations. ⚠️


If the patient is at immediate risk or expressing active suicidal intent, please call 911 or direct them to the nearest emergency department.


You may also contact the National Suicide & Crisis Lifeline at 988.

Referring Person and/or Facility

Patient Information

Birthday
Month
Day
Year
Multi-line address
Does the patient have medical insurance?
Yes
No
Are there any transportation barriers?
Yes
No

Reason for Referral

Services Request:
Urgency Level
Routine
Urgent (within 1-2 weeks)

Safety Screening

⚠️ Important: This form is not intended for crisis situations. ⚠️


If the patient is at immediate risk or expressing active suicidal intent, please call 911 or direct them to the nearest emergency department. You may also contact the National Suicide & Crisis Lifeline at 988.

Is the patient currently experiencing suicidal thoughts?
Yes
No
Unknown
Does the patient have a history of suicide attempt?
Yes
No
Unknown
If available, please attach the following:

Include where and dates completed.

Please upload supporting documentation.

Referral Acknowledgment

This referral form is not monitored for emergencies.


If the patient is in crisis or at immediate risk of harm, do not submit this form.


Call 911, send them to the nearest Emergency Department, or contact the National Suicide & Crisis Lifeline at 988.


By submitting this referral, you confirm that the patient has been informed of and consents to this referral to Enlightenment Psychiatry.

Rebecca

"Amanda is providing an extremely important & needed service within our community. This is the first time I’ve ever had a specific med management person on my wellness team. My overall mental/emotion health has improved since becoming a client. I’m thankful this type of healthcare is now available in our rural area. I have already referred multiple people to their services."

Kristen

"I can't recommend this place enough, everyone I've encountered there has been nothing but kind and understanding. I've seen a few therapists and psychologists, but none of them took the time and the care to understand just who I am and what's going on with me. Highly, highly recommend it especially for those of us who suffer from the effects of complex trauma, dual diagnosis, and grief."

Brianna

"Speaking with Mackenzie for only a few weeks has already changed my life for the better in so many ways. She’s extremely personable, she hears everything you have to say, I would recommend her to anyone!"
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Park Rapids Office

1011 1st Street East

Suite 5

Park Rapids, MN 56470

Detroit Lakes Office

808 Washington Avenue

Suite 15A

Detroit Lakes, MN 56501

Phone (320) 321-9599

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