Athena Care
Behavioral Health Referral Form for Mental Health Services (Physician Referrals)

Behavioral Health Referral Form for Mental Health Services (Physician Referrals)

Illustration of care givers

We value your referrals.

As a physician, you may encounter individuals in need of services or testing in areas that fall outside of your practice or expertise. We’re here for you.

When you refer patients to Athena Care, you’re assured that they’ll receive the highest quality of care. We look forward to the opportunity to serve you and your patients.

Referral form




Alternately you may download, print and return this PDF form.

When Should I Refer Someone for Mental Health Services?

A vital first step is filling out a referral form for mental health services. With early intervention, mental health disorders, such as severe anxiety or depression, can be controlled or prevented, just like any chronic illness.1

Ten Signs That Someone Needs a Referral for Mental Health Services

The following are 10 potential signs that someone may need a referral to mental health services:

  1. Suicidal ideation
  2. Difficulty concentrating
  3. Indifference
  4. Restlessness
  5. Checking news sources or social media regularly
  6. Irregular sleeping habits
  7. Fatigue
  8. Distant or withdrawn
  9. Mood changes
  10. Diet changes

In addition, preventive intervention services may be provided in various settings. For example, there are early intervention programs, home visiting programs, and behavioral health programs, depending on the severity of stressors, including parenting challenges, domestic violence, and family strife. Filling out a psychiatric referral form for more intense and targeted mental health care may occasionally be required to address the needs of children and families.

Are Behavioral Health Referrals Confidential?

Behavioral health referrals and behavioral health referral forms are confidential. To establish the trust necessary for treatment to be effective, privacy is crucial because mental health care entails discussing sensitive personal issues. The confidentiality of health information is protected by both federal and state legislation.2

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 safeguards personal information provided during treatment and information concerning diagnosis and treatment. In some circumstances and emergencies, the provider is permitted to disclose a limited amount of mental health information. Additionally, mental health professionals must abide by Tennessee state health privacy laws.

A healthcare provider may disclose a patient’s information to family members, friends, or those involved in the patient’s care or payment for care when the patient is absent or incapacitated, provided that the healthcare provider determines that doing so is in the patient’s best interests. In addition, the healthcare provider must be reasonably certain that the patient invited the person to be involved in their treatment or payment for care when someone other than a friend or family member is participating.

HIPAA permits these common – and frequently essential – connections between these individuals and healthcare professionals in recognition of the crucial part that family and friends play in a patient’s healthcare. Healthcare practitioners may speak with a patient’s family, friends, or others that the patient includes in their health care or payment for care as long as the patient doesn’t object, is present, and has the mental capacity to make healthcare decisions.3

In all circumstances, the healthcare professional may only disclose or discuss information regarding the patient’s care or payment for care that is necessary for that individual to know. In addition, sharing personal health information may be subject to further restrictions under other applicable laws or professional ethics, particularly when the information relates to a patient’s mental health.

What Happens After I Refer Someone to Athena Care?

As a healthcare professional, you may come across patients who want services or behavioral health assessments in fields unrelated to your practice or area of specialization. When you recommend your patients to Athena Care, you can be confident they’ll get the best care available.

Filling out our free and confidential mental health referral form is the easiest and quickest method to refer someone to one of our multiple mental health treatment clinics in Tennessee.

Athena Care utilizes a comprehensive team of healthcare providers, including doctors, psychiatric nurses, and professional psychologists and therapists. One of our highly experienced, expert care coordinators will reach out upon receiving your mental health counseling referral form to determine the best course of action. You can be sure that a trained staff member will look after your patient’s mental health needs.


  1. A, Monique. “10 Signs You Need to Make a Behavioral Health Referral.” Community Health Worker Training, 9 Apr. 2020, chwtraining.org/signs-stress-behavioral-health-referral.
  2. NAMI Tennessee. “More Information on the Law.” NAMI Tennessee, 5 July 2022, www.namitn.org/mental-health-crisis/help-for-someone-i-care-about/additional-information-and-resources-family.
  3. “HIPAA Privacy Rule and Sharing Information Related to Mental Health.” U.S. Department of Health and Human Services (HHS.gov), www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf. Accessed 2 Nov. 2022.