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Client Referral Form | MindWell Behavioral Health

Client Referral Form

Recommender (Referring Provider) Information

Information of the person submitting this referral.

Your Name

Email Address

Your Organization / Practice

Fax Number

Phone Number

Preferred Contact Method

Phone Email

Client Information

Client's Full Name

Date of Birth

Client Phone Number

Client Email Address (Optional)

Insurance Provider

If Other, please specify

State

Referral Details

Reason for Referral

Primary Concern

Anxiety Depression Trauma / PTSD Relationship Issues Stress Management

Services Requested

Individual Therapy Couples Counseling Family Therapy Medication Management

Additional Information

Upload Supporting Document (Optional)

I confirm that I have the client's consent to share their information.

By submitting this referral form, you are formally acknowledging that the information provided herein is, to the best of your knowledge, entirely accurate and provided with the patient's consent. You acknowledge that the information provided here is for referral purposes only, and no other Protected Health Information (PHI) is to be shared between you as the referring provider and MindWell Behavioral Health without proper written authorization from the patient.

MindWell Behavioral Health strictly adheres to all applicable rules and regulations governing PHI, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). To learn more, see our Notice of Privacy Practices .

Your privacy is important to us. All information shared is secure and confidential.