This form allows you to provide the clinical information necessary for the evaluation and management of your patient. All fields marked with an asterisk (*) are required.


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Referring physician











Current outpatient follow-up *


Patient







Diagnoses


Current clinical status

Depression level



Suicidality level






Reason for referral


Medical problems



Current pharmacological treatment



Attach full treatment if necessary

Treatment history



Include psychiatric hospitalisations, previous pharmacotherapies and their response

Planned outpatient follow-up