(718) 470-8100

75-59 263rd St.
Glen Oaks, New York 11004

Forms for referring providers

If you’re a referring physician or hospital, please download and complete the appropriate patient referral forms listed below:

Medical Readiness List

Please complete the Medical Readiness List and fax it to (718) 470-5699 or email it to [email protected].
 

Inpatient ECT Referral Form

Please attach the documents below to the Inpatient ECT Referral form and fax it to 718-343-0441:

  1. Admission Psychiatric assessment
  2. Last 3 Psychiatry progress notes
  3. Most recent history and Physical exam, CBC, BMP, EKG and Pregnancy test (females, ages 12-55)
  4. If patient is an appropriate transfer for inpatient ECT, we will fax the referring hospital a consent form to be signed by the patient and faxed back to us, before accepting the patient.
75-59 263rd St.
Glen Oaks, New York 11004
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