CONFIDENTIAL FAX TO DOCTOR________________________________________

FAX# _____________________________  Date: ________________
Doctor: _______________________________________________
Office: _______________________________________________
Phone: _______________________________________________
E-mail: _______________________________________________

Dear Doctor,

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,   ____________________________________________________

Name: _______________________________________________
Address: _______________________________________________
  _______________________________________________
Phone: _______________________________________________
FAX# _______________________________________________
E-mail: _______________________________________________

 

 

 

 

 

 

 

 

 

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