Template Referral Letter

Date

Dear Referred Individual's NAME,

You have been referred to CPHP on [DATE] for [ISSUE].

We will expect you to sign releases at CPHP so that the Clinician and evaluating psychiatrist can obtain information from and provide information to the following individuals.

(Note to Referral Party: List any individuals you would like for CPHP to speak with concerning this employee: Suggestions listed)

We expect that you will contact CPHP no later than [DATE] to make an appointment. Once you make an appointment at CPHP, please immediately notify your supervisor, [SUPERVISOR'S NAME] of the date of your appointment. You will receive an appointment letter from CPHP that will document when your appointment has been scheduled; this can be used as appointment confirmation. CPHP will not be able to confirm an appointment directly to us until a Release of Information is signed on the date of your appointment.

CPHP will communicate with [REFERRED INDIVIDUAL] once the evaluation has begun and may request or provide other information regarding your status and assessment.

If you would like more information regarding CPHP see their web site at www.cphp.org.

Sincerely,

REFERRING PARTY

cc: CPHP