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Dr. Seth Williams, PsyD, Licensed Psychologist

Provider Referral Form
Self Referral Form
Welcome

Provider Referral Form

Please complete this form to request a call from Dr. Seth Williams, PsyD about your client’s mental health care needs.

Thank you for your response. ✨

Name(required)

Email(required)

Phone

How did you hear about us?

Other Details

Δ

Thank you for your response. ✨

Name(required)

Address(required)

Date of Birth(required)

Phone(s)(required)

Email(required)

Primary Insurance Company(required)

Primary Insurance Member ID#(required)

Secondary Insurance Company

Secondary Insurance Member ID#

Will meet by TeleHealth? (required)

Yes

No

Will meet in person? (office is in downtown Corvallis) (required)

Yes

No

Referral concerns – Why are you referring your client for mental health care at this time?(required)

Are there any safety concerns?(required)

Yes

No

If there are safety concerns, please provide details.

Do you want ongoing collaboration?(required)

Yes

No

If you want ongoing collaboration, please specify if you will email a release signed by the client to the email address below or if you are requesting that Age Wise secure patient signature.

Will email release

Requesting Age Wise to secure signature

Other comments – Is there anything else you’d like me to know?

Δ

260 SW Madison Ave #113, Corvallis OR 97333

503.752.0122

DrWilliams@AgeWiseOR.com