Referral Request

Emergency Assistance

We do not provide acute or crisis services or DBT on-call phone coaching.

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Thank you so much for considering us for considering our practice for your patient or client!

Our clients are often busy, multipassionate, driven professionals, executives, physicians and healthcare professionals, lawyers, entrepreneurs, athletes, creators, and public figures who want more from life while doing less. Because they need wellness options that optimize their time, offer location flexibility, are uniquely tailored to their needs, and are delivered by highly-trained specialists. Please review our General FAQ and Investment FAQ and keep the following in mind before referring your patients:

We are 100% private pay. We don't accept third party insurance. We do provide superbills for reimbursement and accept some HSA cards.
Our practice is 100% online using a HIPAA-secure telehealth platform and portal. We don't offer in person sessions.
We only work with adults. We work with many psychological problems, but currently we don't accept referrals for therapy with individuals who have serious mental illness (SMI) including psychotic disorders, personality disorders, or disorders that could make the medium of telehealth too challenging for the patient to benefit.
Our psychologists are all members of PSYPACT, so we can work with clients in over 39 states.
All of our psychologists have PhDs in clinical psychology representing the highest education and training in our field.

New Referral Information

First name

Last name

Email address

By entering your email address, you agree to be contacted by our staff via email.

Phone number

Physical Location for Online Telepsychology Services

Please indicate the state where your patient will be physically located during all sessions.

If your patient is located in a non-PSYPACT state (e.g., NY, MA, or CA), we can't work with them at this time. Please contact us, and we will try to assist with referrals as appropriate.

I understand that all therapy and assessment services are offered exclusively online.

Most of our clients are busy professionals and graduate students who don't want to commute for services and many live in other states. If you are looking for in-person services, please let us know, and we will try to connect you with resources.

What services does your patient need?

I'm interested in the following services (please check all that apply):

Individual Therapy - Adult (18 and up)

Parenting

ADHD, Autism, or Neurodiversity Evaluations

(Dr. Hasek only)

Trauma / PTSD Evaluation

(We don't do forensic or VA assessments)

Psychological Evaluation

(e.g., differential diagnosis)

Retreats / Workshops / Courses / Groups

Executive Coaching with Dr. Newman

(visit drjannewman.com for application)

How would you like us to respond?

If the provider would like us to contact them, please include email and phone. Email works much better for our providers due to their schedules. If you would like us to contact the patient directly, please note that:

We do not contact patients directly based on your referral form unless you include a signed authorization along with this request.
In general, we recommend that you send this referral form and then ask your client to complete our intake form as well. Here is the link: Request an Appointment - Momentum Psychology, PLLC (hushforms.com)

Please respond by:

Desired Provider

Please click here for a list of our current psychologists and their bios.

Please select your desired provider from the list below. If you're not sure who would be a good fit and need help, please include that in your comments.

Dr. Kayleigh Hunnicutt Dr. Jenny Shields Dr. Sarah Lyle Dr. Jan Newman

(waitlist for therapy until spring 2025)

Not sure which one is the best fit, but we have described concerns below.

Click here to check out our providers' rates.

Here are things that I want the provider to know about this referral.

About the Patient and Their Concerns

Which most closely describes patient's gender? MP is committed to affirming all sexual and gender identities.

Man Woman Non-Binary Prefer Not to Say Other

If you would like, please describe in comments.

What is patient's age range?

0 - 18 19 - 24 25 - 35 36 - 49 50 - 65 65 +

Please note any diagnosis you have made or are aware of from history:

How did you hear about us?

Yes, I want free resources!

Want to stay connected? We believe in self-empowerment! Please check here or click on this link if you would like to be added to our email list to learn about new tools and resources for personal development.

Want free stuff right now? For free resources, check out our blog and all of our curated resources in one place.

Need help with managing stress and burnout FAST? Check out our services and this blog article with 7 tips from a psychologist on how to slay stress and banish burnout.

Process

We will try to respond to your request within 1 - 2 business days. Please contact our office at 704-444-0087 or email our Client Coordinator, Kristin Coen, at hello@momentumpsychology.com for more information.

*Your submission of this appointment request does not constitute a therapeutic relationship. By submitting this form and including your email, you are consenting for us to contact you about scheduling via email.

Your information will be encrypted.

Referral Request

Emergency Assistance

New Referral Information

Physical Location for Online Telepsychology Services

What services does your patient need?

How would you like us to respond?

Desired Provider

About the Patient and Their Concerns

Process

Emergency Assistance

Momentum Psychology, PLLC