Tully Hill

Outpatient Agency / Clinician Referral Form

If you can’t use the form below you can print out,  complete and send us our Outpatient Agency/Clinician Referral Template via e-fax (315) 413-5106 or main fax (315) 696-8509.

Client Demographics:

Insurance Information:

Presenting Problem:

Please send us a copy of the client’s current evaluation & psychosocial bio, any drug screen results, a signed Release of Information, and your cover sheet.

Email: tullyhillintake@tullyhill.com // Efax: (315) 413-5106 // Fax: (315) 696-8509

YOUR PATIENT MUST CALL US AT: (315) 696-6114 or (800) 456-6114 / extension 122, 126, or 127.

We will then finish our admission pre-screen with your client (we will need to obtain from him or her medical information, treatment and medication history, and employer and any past or pending legal information) and get back to you if we have any questions, or need more information.