Professional Referral Form

If you are a medical professional looking to make a referral to Mindful Mending, please complete the form below. A member of our team will review and contact you shortly.

When we contact you, we will need an ROI completed and then the following information:

• What days and times is the client typically available for sessions?

• What insurance will they be using? (We accept Anthem/BCBS, UHC Medicaid, Passport Medicaid, UHC Commercial, and Private Pay)

• General reason for therapy

• Legal first and last name of client

• Date of birth

• Phone number they would like connected for appointment reminders

• Email address they would like connected for intake paperwork and telehealth sessions

The client or family can also reach out by using the “Contact Us” button or email us at hello@mindfulmending.com. They can provide the above information if they are unable to complete the ROI.

Do not use this form if you have a medical emergency or urgent problem. Instead, please contact 911 or seek the nearest emergency room right away.