Refer a Patient

Thank you for considering YOU Psychiatry Clinic

We warmly welcome referrals from healthcare providers and partner organizations. Our dedicated team delivers compassionate, collaborative, and evidence-based mental health care tailored to each adult’s unique needs. We look forward to partnering with you to support your patient’s well-being.

Who Can Refer?

We welcome referrals from a wide-range of healthcare professionals, including:

Primary Care Physician
Providers of Other Medical Specialtie
Day Programs (Partial Hospitalization and Intensive Outpatient
Psychiatric Provider
College Counselor
Social Worker
Psychologists and Therapist
Speech, Occupational, and Physical Therapist
Other Licensed Healthcare Professionals

If you are a healthcare provider not listed here or uncertain whether a referral is appropriate,
please contact us at admin@youpsychiatryclinic.org. Our team is available to support you and
provide guidance throughout the referral process.

Online Referral Order Requisition Form

Please complete the HIPAA compliant form below to refer a patient to YOU Psychiatry Clinic. Once we receive your submission, our administrative team will review the details and respond via your provided email within 2 business days to provide insurance verification information and offer an appointment for an initial psychiatric evaluation. If you do not hear from us, please do not hesitate to contact us at admin@youpsychiatryclinic.org. Thank you for trusting us. We value our community partners and look forward to working together to support our patients’ mental wellness.

Please note: This form is intended solely for healthcare providers or organizations referring patients for outpatient psychiatric care.

PATIENT DEMOGRAPHIC INFORMATION

First Name*

Last Name*

Gender Identity*

Preferred Pronouns

Full Address*

Example: 1234 Chicago Ave, Chicago, IL 60606

Email*

Phone*

Front Of Insurance Card*

Back Of Insurance Card*

If patient is uninsured or out-of-network, please select one:*

REFERRAL ORDER INFORMATION

Referral Reason: Indicate consult, treat, or both (patient may be referred within the practice if clinically indicated). *

Diagnoses:*

REFERRING PROVIDER INFORMATION

Provider Name:*

Title/Position*

Organization Name*

Address*

Phone Number*

NPI Number*

By typing your full name below, you are providing your electronic signature. This confirms that the information you’ve provided is true and complete to the best of your knowledge, and that you consent to be referred to YOU Psychiatry Clinic. You must also check the box to finalize your submission.

I confirm that the information above is accurate and I consent to this referral. *

Electronic Signature*

Date*

Immediate Appointments For Telepsychiatry, Hybrid, and In-Person Scheduling.

Immediate Appointments For Telepsychiatry, Hybrid, & In-Person Scheduling. Call/Text (708) 765-6340

Refer a Patient

Thank you for considering YOU Psychiatry Clinic

Who Can Refer?

Online Referral Order Requisition Form

REFERRAL ORDER INFORMATION

REFERRING PROVIDER INFORMATION

By typing your full name below, you are providing your electronic signature. This confirms that the information you’ve provided is true and complete to the best of your knowledge, and that you consent to be referred to YOU Psychiatry Clinic. You must also check the box to finalize your submission.

A referral is a vote of confidence, a testament to your care

BE WELL, BE YOU

BE WELL, BE YOU

Refer a Patient

Thank you for considering YOU Psychiatry Clinic

Who Can Refer?

Online Referral Order Requisition Form

REFERRAL ORDER INFORMATION

REFERRING PROVIDER INFORMATION

A referral is a vote of confidence, a testament to your care

BE WELL, BE YOU

BE WELL, BE YOU

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