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Soma Integrated Psychiatric

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Referral Form
Referral Form

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Provider Referral Form

Use this online form to easily submit patient referrals from your practice to Soma Integrated Psychiatric.

This form is end to end HIPPA compliant for PHI.

Referring Provider Information

Referring provider / practice name*

Referring contact person

Referring phone*

Referring fax

Referring email

Patient Information

Patient first name*

Patient last name*

Patient date of birth (MM/DD/YYYY)*

Patient phone*

Insurance carrier*

Reason for referral

Appointment type

Urgency

Routine referrals will typically be scheduled within 2 weeks.

Urgent referrals will be attempted to be scheduled within 1 week.

Soma Integrated Psychiatric

2111 E Baseline Rd Ste C6
Tempe, AZ 85283-1521

Ph 480-382-8284 . Fax 480-933-8422

contact@somaintegratedpsych.com

© 2026 All Arizona Wellness PLLC. Care provided by Liana Flores, MSN, APRN, FNP-C, PMHNP-C, PMGT-BC, a certified Psychiatric-Mental Health Nurse Practitioner.

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