Therapy & Mind | Telehealth Psychiatry & EMDR Therapy

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Response Time We contact referred patients within 1–2 business days.

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Questions? Email info@therapyandmind.com

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Secure & Confidential Handled in full HIPAA compliance.

Section 1

Referring Provider Information

Provider Name *

Credentials / Title *

Practice / Organization *

Specialty

Phone *

Fax

Email *

Section 2

Patient Information

Patient Full Name *

Date of Birth *

Patient Phone *

Patient Email

State *

Insurance (if applicable)

Section 3

Referral Details

Services Requested *

EMDR Therapy — Trauma-focused, somatic processing for PTSD, anxiety, and past trauma Psychiatric Evaluation & Medication Management — Diagnosis, medication consultation, ongoing care Individual Therapy — Evidence-based talk therapy Telehealth — Preference for virtual sessions

Urgency

Routine (2–4 weeks) Soon (1–2 weeks) Urgent (within days)

Primary Reason for Referral *

Section 4

Authorization & Submission

HIPAA Notice: By submitting this form you confirm that you have a valid basis under HIPAA to share this patient's protected health information for treatment purposes, and that all information provided is accurate to the best of your knowledge.

I confirm I have authorization to share this patient's information for the purpose of treatment referral. * The patient has been informed of and consents to this referral. Please contact me with an update once the patient has been reached.

✓ Referral Submitted Successfully

Thank you for trusting Therapy & Mind with your patient's care. Our team will follow up with the patient within 1–2 business days. If you requested a status update, we will reach out to you at the email provided.

✓ Referral Submitted Successfully

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info@therapyandmind.com