If you’re a referring physician or hospital, please download and complete the appropriate patient referral forms listed below:
Please complete the Medical Readiness List and fax it to (718) 470-5699 or email it to [email protected].
Please attach the documents below to the Inpatient ECT Referral form and fax it to 718-343-0441:
- Admission Psychiatric assessment
- Last 3 Psychiatry progress notes
- Most recent history and Physical exam, CBC, BMP, EKG and Pregnancy test (females, ages 12-55)
- 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.