WELL COAST MEDICAL CORPORATION

Outside Clinician Referral Screening Form

Thank you for considering Well Coast for a psychiatric referral. To make a referral, please 

(a) complete this Screening Form; AND (b) fax the Face Sheet and Evaluation Notes to: (877) 448-3551. 

Once this form has been submitted, the patient would receive an email inviting them to self-schedule an intake appointment.

Again, thank you for the referral.