Referring Form

Provider referral

For referring providers. Takes about six minutes. You can save and finish later.

Step 1 of 3Provider

Step 2 of 3Patient

Step 3 of 3Referral

Referring provider information

Please provide information about the referring provider and practice.

Referring provider name * Professional credentials * Practice or organization name * Provider specialty (optional) NPI number * Used to verify the referring provider.

How we reach you

Phone number * Fax number (optional) Secure email address * Used for the resume link and, if requested, the consultation summary.

Preferred contact method *

PhoneSecure emailFax

Referral coordinator or contact person (optional)

Patient information

Please provide basic contact and insurance information for the patient being referred.

Patient full name * Date of birth * Phone number * Email address (optional) Home address (optional) City (optional)

State * ZIP code (optional)

Preferred contact method *

PhoneText messageEmail

May we leave a voicemail? *

YesNo

Preferred language (optional)

Does the patient currently reside in Minnesota? *

YesNo

Outside the current service area WholeMind provides telehealth care to patients located in Minnesota. You can still submit this referral, and the team will contact the patient about options if the patient is relocating or will be in Minnesota at the time of care.

Payment information

How will the patient pay for services? *

InsuranceSelf-payUnsure

INSURANCE DETAILS

Insurance company Member ID Group number (optional) Policyholder name Relationship to policyholder

Insurance card, front

Insurance card, back

Self-pay selected The patient has selected self-pay and understands that payment may be required at the time of service.

Payment options to be reviewed The practice will review available payment options with the patient before scheduling.

Reason for referral

Please provide the clinical information needed to review the referral and determine the appropriate next step.

Primary reason for referral * Select all that apply.

AnxietyDepressionPregnancy-related mental health concernsPostpartum depression or anxietyPerinatal mood or anxiety concernsPremenstrual dysphoric disorderAdult ADHD evaluation or treatmentTrauma-related symptomsMood instabilityMedication evaluationPsychiatric medication managementPreconception psychiatric consultationOther

Clinical details

Describe the patient’s primary symptoms, concerns, and treatment needs *

Current mental health diagnoses (optional) Relevant medical diagnoses (optional) Current psychiatric medications (optional) Previous psychiatric medication trials (optional)

Current therapist or behavioral health provider (optional) Relevant pregnancy, postpartum, or reproductive health information (optional) Additional clinical information (optional)

Referral urgency

How urgent is this referral? *

RoutineClinically urgentImmediate safety concern

This form is not intended for emergencies

Call 911, contact an appropriate crisis service, or direct the patient to the nearest emergency department. Patients and providers in Minnesota can also call or text 988 to reach the Suicide and Crisis Lifeline. This referral will not be reviewed in real time.

I understand this form is not monitored for emergencies and I have arranged appropriate immediate care.

Safety screening

Is the patient currently experiencing suicidal thoughts? *

YesNoUnknown

Is there a history of suicide attempts or self-harm? *

YesNoUnknown

Are there current substance use concerns? *

YesNoUnknown

Has the patient previously been psychiatrically hospitalized? *

YesNoUnknown

Supporting documents

Upload any available records. Optional, but they speed up triage.

Attach Clinical Documents (PDF, JPG, PNG, DOCX)

Care coordination

Would you like a consultation summary after the evaluation? *

YesNo

Would you like ongoing care coordination when clinically appropriate and authorized by the patient? *

YesNo

Provider attestation

I confirm that the patient is aware of this referral and has authorized the sharing of information necessary to coordinate care.

I confirm that the information provided is accurate to the best of my knowledge. I understand that submitting this referral does not guarantee acceptance, confirm appointment availability, or establish a provider-patient relationship.

Provider name * Submission date * Electronic signature * Typing your name applies a legally binding electronic signature.

✓

Referral submitted successfully

Thank you for referring your patient to WholeMind Wellness & Psychiatry. Our team will review the referral and contact the patient regarding eligibility, appointment availability, insurance verification, and next steps.

Reference number WM-2026-00000

What happens next

A confirmation goes to your secure email within a few minutes.
The clinical team reviews the referral within one business day.
The practice contacts the patient by their stated preference within one to three business days.
You are notified whether the referral was accepted, and a consultation summary follows the evaluation if you requested one.

Submitting a referral does not guarantee acceptance into the practice or establish a provider-patient relationship. If the patient’s condition changes and immediate care is needed, call 911 or direct the patient to the nearest emergency department.