TO: _____________________________________________________ (fax: 281-373-5202)

Please call patient to schedule appt.

Patient will call you.

Other: _______________________________

Date: _____________________________________ Patient Name: Parents Name (if patient is a minor) Primary Contact No.: Patients Address: Primary Medical Insurance:________________________________ Insurance Phone No. Insured ID #: _______________________________________________ Name of Primary Subscriber: Subscriber DOB: _ ________________________ Alternate Contact No.: __ DOB: _____ Gender: F / M ___________

Reason for Referral (Diagnoses/Symptoms of Concern)

Type of treatment requested Individual Counseling Family Counseling Other: ______________________________

Patient has / has never been seen by Dr. Thompson for a psychological evaluation.

Appointment is scheduled with: _________________________________ (HOPE therapist) on ____ _________ (date) at Therapist contact number: _________________________________________. __________ (time).

Patient needs psychological testing

Patient does not need psychological testing at this time

CONFIDENTIAL NOTICE: This facsimile, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information or otherwise protected by law. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of the original facsimile. Rev 04/2013