Patient Referrals - OptiMindHealth, Holistic Mental Health Specialists

Patient Information

If you are a healthcare provider or a provider representative seeking to refer a patient to OptiMindHealth, please complete the secure form provided below. Ensure that all relevant information and documents pertaining to the patient referral are included and attached. Providing accurate information is essential to secure the rapid scheduling of your referral and the highest standard of care for your patient. All information provided on this secure form will be treated with strict confidentiality. We appreciate your cooperation and collaboration.

Select Your Desired OMH Office*
Your Patient's Full Name
Your Patient's Phone
Your Patient's Email
Name of Person Completing This Form*
Name of Your Practice*
Your Phone*
Your Email*
Reason For Referral and Clinical Summary*
Documents Related to Your Referral
Drop files here or

Max. file size: 200 MB, Max. files: 6.
Documents can include any pertinent labs, forms, testing or diagnostic data that we should review before seeing your patient.
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Email
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