CONFIDENTIAL FAX TO DOCTOR________________________________________
|FAX# _____________________________ Date: ________________|
I am terribly depressed. I am so very sad and cry all the time.
I am often suicidal and am afraid that I might not make it through.
I have been feeling this way for __________________ weeks. months, years.
My other symptoms are _______________________________________________________________________
I would like to try an antidepressant and/or see a therapist as soon as possible.
I feel so ashamed and I am too embarrassed to come in or even send this note.
Is there anyway you could call me ?
My Phone Number is _______________________________________________________
The Best Time to Call Me is _________________________________________________
Do I need to come in for an appointment ? or do I need a referral ?
Thank You. Sincerely, ____________________________________________________
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