Contact — Healthy Minds Network

Referral Form

Fill out some info and we will be in touch shortly! We can't wait to hear from you!

Please complete all required field in order to submit form.

Client Information

First Name

Last Name

Date of Birth

YYYY

Gender

Ethnicity/Race

Phone

(###)

###

####

Insurrance

We are currently only accepting medicaid clients and out-of-pocket clients

Medicaid

Out-of-Pocket

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation (employed, student, unemployed....)

Reason for Referral

Availability

Please list all available time frames and days available for therapy.

Guardian Information (If applicable)

First Name

Last Name

Phone

(###)

###

####

Relationship (mother, father, etc...)

Client's School and Grade Level

How did you hear about us? (If applicable, please add referral source name and contact info)

For general questions. Please see “Referral Form” tab for referrals or scroll up.