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Clinician Information
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Patient Information
Refer a patient to Klarisana
Referring Clinician Information
Your Name
Clinician filling out this form
Clinic Name
If applicable
Your Credentials
MD. DO, PsyD, etc.
Your Treatment Role
Patient's psychiatrist, family doctor, therapist, etc.
Your Phone Number
Your Email
This form is intended for use by medical professionals who wish to refer a patient to Klarisana. If you are a patient who wishes to be seen at a Klarisana center please fill out the "contact us" form on our website at Klarisana.com or call 210-556-1430
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Patient Information
Patient Name
Date of Birth
Patient's Biological Gender at Birth
Female
Male
Gender patient identifies as
Same as biological
Female
Male
Phone
Patient Email
If known
Primary Diagnosis
Secondary Diagnosis
If applicable
History
Please briefly describe any pertinent medical and/or psychiatric history.
Context
Please describe any significant factors we should be aware of with regards to social history, substance abuse, living situation etc.
Would you like one of our clinicians to contact you prior to treatment?
Yes
Not necessary
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