Provider referrals – Northline Psychiatry

What we offer your patients

Psychiatric evaluation and ongoing medication management — available now
Individual therapy with W-2 licensed therapists — available now
Spravato (esketamine) for treatment-resistant depression — coming soon
TMS for depression and OCD — coming soon
In-person at our East Lyme office or via secure telehealth across Connecticut
In-network with most major commercial plans in CT

Typical scheduling

Most referred patients are scheduled for an initial evaluation within 1 business day. Urgent referrals (within 48 hours) can be accommodated when clinically warranted — please indicate urgency on the form below or call.

After the referral

You’ll receive:

Confirmation that we’ve received the referral within one business day
Notification when the patient is scheduled
A brief evaluation summary after the initial visit (with the patient’s written consent)
Periodic clinical updates and notification of significant treatment changes

Submit a referral

Complete the form below or, if you prefer, call us at (860) 385-6547 or fax to (203) 555-0145.

Referring provider

Your name *

Practice / institution

Your NPI

Specialty / role

Email *

Phone *

Fax (for records)

Best way to reach you

Patient information

Patient name *

Patient date of birth *

Patient phone *

Patient email

Insurance carrier

Best way to contact patient

Clinical context

Service requested *

Primary diagnosis or clinical concern *

Current psychiatric medications

Relevant treatment history

Urgency *

Safety concerns

Records and consent

I have obtained the patient’s verbal or written consent to share this information with Northline Psychiatry. *

I am sending records separately (fax, secure email, or HIE).

Please send me a brief evaluation summary after the patient’s first visit (with their written consent).

Anything else we should know?

Confidentiality. This form is for referring clinicians only. The information you submit here will be treated as protected health information and handled in compliance with HIPAA and Connecticut state law. We do not share referral information beyond our clinical team.

If your patient is in immediate danger, please call 988 (Suicide and Crisis Lifeline), the Mobile Crisis Intervention Services number for your area, or send the patient to the nearest emergency department. Do not use this referral form for emergencies.

Refer a patient to Northline.

What we offer your patients

Typical scheduling

After the referral

Submit a referral

Referring provider

Patient information

Clinical context

Records and consent