Response Time
We contact referred patients within 1–2 business days.
Questions?
Email info@therapyandmind.com
Secure & Confidential
Handled in full HIPAA compliance.
Section 1
Referring Provider Information
Section 2
Patient Information
Section 3
Referral Details
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.
✓ 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.