State of Mind Health & Wellness

Provider Information:

Name of Referring Provider

Referral Date:

Address

Phone

Email Address

Reason of Referral: Check all that apply

Consultation

Evaluation

Medication Management

Phone Consultation Only

Name

Date of Birth

Address

Email Address

Contact Number

Gender

Photo Of Government Identification: Front and Back

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Please upload a file

Name

Mobile Number

Address

Are you currently seeing a therapist?

Yes

If yes, please fill information below:

Name

Phone

Address

Do you have insurance?

Yes

Out of Pocket

If yes, please fill information below:

Insurance Company

Member ID

Group

Photo of Insurance Card: (Front and Back)

Add file

Please upload a file

Reason for Seeking Treatment/ Diagnosis (If applicable)

Please use the following for any additional pertinent information, special requests or patient expectations:

*Please note if the referral is submitted incomplete it will be returned to you for completion*

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