It's the handover document when a client's mental health care moves between providers. The receiving clinician often has to decide how quickly to see the person, and whether their service fits at all, before speaking to anyone. Current risk, what has already been tried, and what the referrer wants from them drive that decision.
For a referral with no mental health angle, such as a sleep study or a cardiology opinion, the patient referral form template fits better.
Which direction is the referral going?
| | What the receiving clinician needs most |
|---|
| Primary care, a school, an employee assistance program | Screening scores with dates, why now, any medication already started, what the client has been told |
To a psychiatric prescriber | | Diagnosis, course of symptoms, therapy so far, current medications and who prescribes them, the medication question |
To a higher level of care | Therapist or psychiatrist | Current risk, decline in day-to-day functioning, why weekly outpatient care isn't enough |
| | Eating disorder, trauma or substance use history, and what suggested specialty care |
| Therapist or psychiatrist | Diagnosis, treatment given, current medications, what to watch for and when to refer again |
What each section holds
Much of the form matches any referral: client details, insurance, the referring clinician's contact information, urgency. These sections are the ones that make it a mental health referral:
- Risk summary: current suicidal or homicidal thoughts, recent self-harm, the date and tool of the last risk assessment, and whether a safety plan is in place.
- Screening and outcome measures, each with its date, for example PHQ-9, GAD-7, PCL-5 or AUDIT, so the receiver can see the trend.
- Diagnosis or working diagnosis, with the ICD-10-CM code if one has been given.
- Treatment so far: modality, number of sessions, what helped and what didn't.
- Medications and prescribers: every psychiatric medication, the dose, and who prescribes it now.
- The question: medication evaluation, diagnostic clarification, a higher level of care, or ongoing therapy.
- Client preferences: language, clinician gender, in person or telehealth, cost and network.
- Consent and records: what the client agreed to, what's attached, and what's deliberately left out.
Priya (fictional), 27, has seen her therapist weekly for 10 sessions for generalized anxiety disorder. CBT has eased her worrying at home, but panic at work is getting worse and she has asked about medication. Her therapist refers her to a psychiatric nurse practitioner.
| |
|---|
| Therapist to psychiatric prescriber, for a medication evaluation |
| F41.1, generalized anxiety disorder |
| GAD-7: 17 at intake on August 5, 2026, 14 on October 7, 2026. PHQ-9: 8 on October 7. |
| Denies suicidal or homicidal thoughts. Columbia screen negative on October 7, 2026. No history of self-harm. |
| 10 weekly CBT sessions: worry postponement, cognitive restructuring, and interoceptive exposure since session 8 |
| No psychiatric medication. Daily oral contraceptive from her gynecologist. |
| Is medication indicated alongside continued CBT? Please send your evaluation and any prescription you start, so we can coordinate. |
| |
| Telehealth, evening appointments, in network with her employer's plan |
| Priya agreed to the referral and signed a release on October 8, 2026 so both offices can exchange updates. |
| Intake assessment summary, current treatment plan, GAD-7 and PHQ-9 history |
| |
A primary care physician refers Mr. Okafor (fictional), 64, to therapy. His wife died five months ago. His PHQ‑9 is 16, he denies suicidal thoughts, and the physician started sertraline last week and will keep prescribing. The physician's question is whether this is grief that needs support or a depression that needs treatment. If the therapist's evaluation finds uncomplicated grief, the ICD‑10‑CM index sends bereavement to Z63.4, disappearance and death of family member.
- Date and referral type: into therapy / to a prescriber / higher level of care / specialty program / back to primary care
- Client name, date of birth, phone, pronouns, preferred language:
- Insurance or payment:
- Referring clinician, credentials, phone, secure contact:
- Referred to:
- Diagnosis or working diagnosis, with ICD-10-CM code:
- Screening and outcome measures, with dates:
- Current risk (suicidal or homicidal thoughts, self-harm, date and tool of last assessment):
- Safety plan in place: yes / no
- Treatment so far:
- Current medications, doses and prescribers:
- Who will prescribe after the referral:
- Question for the receiving clinician:
- Urgency: routine / within ___ days / urgent (phoned on ___)
- Client preferences:
- Consent: client agrees to referral / release signed on ___ / what the release covers:
- Records attached:
- Referring clinician signature and date:
Consent and what not to send
HIPAA treats a referral as a treatment disclosure, so most of the record can go to the receiving provider without a signed authorization. Psychotherapy notes are the exception. 45 CFR 164.508(a)(2) requires the client's authorization for nearly every use or disclosure of them, and sending them to another provider isn't one of the carve‑outs. Attach a treatment summary or the treatment plan instead. Both belong to the regular record, since 45 CFR 164.501 excludes summaries of diagnosis, treatment plan and progress from the definition of psychotherapy notes.
Substance use treatment records have their own rule. Information from a federally assisted program covered by 42 CFR Part 2 needs the client's written consent before it's shared. Under 42 CFR 2.33, a client can give a single consent for all future treatment, payment and health care operations, after which the records can be used and disclosed as HIPAA allows until the client revokes it in writing.
A signed release is still worth getting for most mental health referrals. It lets the receiving office call back with questions, and it shows the client exactly what's being shared.
A referral form is for planned care. If a client is at imminent risk, don't send a form and wait: arrange an emergency evaluation, call 911, or connect them with the 988 Suicide and Crisis Lifeline. Write up the referral afterward, for the record and for whoever sees them next.
Common mistakes
- Leaving the risk section blank because the screen was negative. Write that it was negative, with the tool and the date.
- Scores without dates, so the receiver can't tell whether things are improving or getting worse.
- Not saying who prescribes. When a client is referred for medication, the form should say whether primary care keeps prescribing or hands it over.
- Referring to a clinician who isn't taking new clients or isn't in the client's network. Check before the client is given the name.
- No follow-up call. A client who was nervous about starting therapy may never book the first appointment.
Billing the visits on either side
The receiving clinician usually starts with a diagnostic evaluation: 90791, or 90792 when the evaluation is done by a prescriber and includes a medical assessment. Brief screening tools such as the PHQ‑9 or GAD‑7, given in primary care before the referral, are often billed with 96127. The diagnosis in Priya's example is F41.1.
CPT is a registered trademark of the American Medical Association. CPT codes copyright 2026 American Medical Association. All rights reserved.
Writing referrals with Twofold
Set the sections above up as a template in Twofold and dictate the referral after the session. Twofold drafts it in that layout, and you check the risk section and the list of attachments before it goes out. More on how drafting works on our AI therapy notes page.
The treatment summary template is the usual attachment. On the receiving side, the therapy intake assessment template or a psychiatric evaluation picks up where the referral leaves off. For risk, see the mental health risk assessment, and for the release itself, the medical release form.
Reviewed and updated October 2026.
