Provider Referral Form | Viking Psychiatry & Wellness

provider referral

Start Your Patient’s Path to Better Health

Please complete the form below to initiate a referral to Viking Psychiatry & Wellness.
Our team will contact the patient promptly to coordinate their care.

Referring Provider Details

Provider Full Name*

Practice Name*

Email Address*

Direct Phone Number*

Practice Address

Patient Information

First Name*

Last Name*

Date of Birth*

Phone Number*

Email Address

Home Address

Preferred Contact Method

Phone Call Email

Consent to leave voicemail

Allow our clinic to leave detailed messages regarding care.

Referral Details

Reason for Referral*

Suspected / Diagnosed Condition(s)

Treatment of Interest (Optional)

Leave unspecified if you would like our team to evaluate the best treatment path during consultation.

Clinical History

Brief Patient History

Current & Past Medication Trials

Notable Side Effects or Responses

Insurance Details

Primary Insurance Provider

Policy / Member ID #

Group #

Policyholder Name (if different from patient)

Supporting Documents & Notes

Attach any relevant clinical notes, previous evaluations, or specific requirements (e.g., PHQ-9 scores for Spravato) that may assist in the evaluation process.

Additional Notes

I consent to receive marketing text messages, about special offers, discounts, and service updates, from Viking Psychiatry & Wellness at the phone number provided. Message frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

I consent to receive non-marketing text messages from Viking Psychiatry & Wellness about appointment reminders, confirmations, and treatment instructions. Message frequency may vary, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Start Your Patient’s Path to Better Health

Referring Provider Details

Patient Information

Referral Details

Clinical History

Insurance Details

Supporting Documents & Notes

Our Practice

Get Started

Proof & Content

Locations

Payments & Access