Referrals – Soul Spring Psychiatry PLLC

Resources

Patient Referral Form

WHAT WE WORK

Anxiety and depression are different for absolutely everybody

Connect with Psychiatric

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Medical team review

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FREE medicine delivery

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Ways to Submit Referral

Please submit the completed referral form via one of the following methods:
Email: info@citrinehw.com
Fax: (909)-310-8482
Citrine Health and Wellness PLLC
Attention: Roudette Ferrer, APRN, ACNPC-AG, PMHNP-BC

Full Name

Date of Birth

Gender

Male Female Other

Phone Number

Address

State

Postal Code

Referring Clinic Information

Clinic Name

Phone Number

Fax Number

Clinic Address

Refering Provide Name

Title Role

Referring Clinic Information

Primary Insurance Provider

Primary Insurance Holder

Policy Number

Group Number

Referral Information

Reason for Referral (Please check all that apply)

Psychiatric Evaluation Psychiatric Medication Management Brief Psychotherapy/Other (please specify):

Symptoms

Consultantion

915-955-2238

Telephone

9159552238

Email

admin@soulspringpsychiatry.com

Location

2100 Georgia Dieter Dr.#960213. El Paso Tx 79936

Patient Referral Form

Find treatment for

Find treatment for

Find treatment for

WHAT WE WORK

Anxiety and depression are different for absolutely everybody

Connect with Psychiatric

Medical team review

FREE medicine delivery

Ways to Submit Referral

Consultantion

Telephone

Email

Location

WHO WE SERVE

OUR SERVICES

RESOURCES

ABOUT