Varad Referral Form | Varad Integrative Psychiatry Clinic For Mental Health And Holistic Wellness Center Bellevue

Referral Form

Routine Urgent

Referring Provider Information

Patient Information (Please provide copy of patient demographics/face sheet)

Male Female


Reason for Referral

Major Depressive Disorder Bipolar Disorder ADHD/ADD
Anxiety Disorder

Provider Requested

Farrukh Hashmi Cheta Nand, MD Kishore Varada, PA-C
Holistic Providers

Type of Service Required

Psychiatric Medication Management Psychotherapy Holistic Treatments
TMS(Transcranial Magnetic Stimulation) Therapy Suboxone Program (opioid use disorder) QEEG (Neuro Feedback)
Documentation Required-Please FAX with this Form to Varad Referral Center at (425) 429-3751

  • Copy of relevant medical records and last note session
  • Lab reports
  • Proof of Insurance
  • Release of Information

I understand and accept the protocol listed above. Failure to comply may subject immediate termination of prescriptive medications.

Your signature below indicates your agreement to the above policy and all of the conditions herein.

Patient/Guardian Signature