Provider Forms
Below you will find downloadable forms that can be filled out digitally. Click on any form to download it, then open it in Adobe Acrobat Reader or your preferred PDF viewer to fill in the fields. Provider information has been pre-filled for your convenience.
Something Human Mental Health – Referring Provider Screener
Use this form when referring patients to Something Human Mental Health providers (Jess Trottier, Tammy Johnson, or Rachel Ward). The form includes a pre-referral checklist and provider-specific criteria to help route your patient to the right clinician.
Leave of Absence – Provider Certification Forms
This combined form includes the Attending Provider Statement (Short-Term Disability Certification) and the FMLA Health Care Provider Certification. Opens as a Google Doc for easy filling. Provider signature sections are pre-filled with practice information.
Something Human Mental Health – Patient Referral Form
Use this form to refer patients directly to Something Human Mental Health for psychiatric care, therapy, or holistic support services. Referring provider information has been pre-filled with practice details.
NW Ketamine Infusion – Referral Request Form
Use this form to refer patients to NW Ketamine Infusion for ketamine infusion therapy or nitrous oxide therapy. Referring provider information has been pre-filled with practice details.
Note: These forms are best viewed and filled out using Adobe Acrobat Reader (free download at get.adobe.com/reader). Some mobile PDF viewers may not support all fillable fields.