New York-Presbyterian / Weill Cornell Psychiatry Patient Referral Portal

Referrer information:

Your first name*

Your last name*

Your title/role

NYP / WCM Clinic Name and Location

Your phone

Your email

Patient information:

Patient's first name*

Patient's last name*

Patient's date of birth*

Patient's phone number**

Patient's email*

Patient Address*

Patient's State*

Patient's Zip Code*

Patient insurance information:

Patient's Insurance Type*

Forge Health partners with most major insurance companies. *Medicaid and Medicare are accepted at select locations.

Patient's Insurance Provider:*

If your insurance provider is not on this list, please select “Insurance Not Listed”

Patient's member ID:*

Your member ID can be found on your insurance card. If your member ID is alphanumeric, please include both the letters and numbers you see on your card.

List Insurance Provider Here:*

Please provide the name of your insurance company and upload images of both the front and back of your insurance cards.

How can we best support your patient?

What is the patient's preferred service delivery method?

In Person

Telehealth

What is the patient's primary need?

Mental Health

Substance Abuse / Addiction / Alcohol

Other

Which level of care are you recommending for the patient?*

IOP (Intensive Outpatient)

OP (Outpatient)

Psychiatric Evaluation

Medication Management

Other

Tell us a little more about the patient and their current needs

Clinical documentation (as applicable):

Drop files here or

Max. file size: 5 MB, Max. files: 5.

Please include any current medications, psychiatric history, most recent clinical note, and PHQ9, GAD7 or any other available behavioral health screening inputs.

Location Preference:

Patient's Preferred Location for Services:*

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