Find Me A Referral

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*Be sure to let them know you have completed a REFERRAL REQUEST FORM with Mindcare Today so our admin team will forward to them and document you have secured support.

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Last Name

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Today's Date

I give consent to Mindcare Today Mental Health Magazine to share my confidential information to have referral sources contact me to further discuss my mental health needs. I understand that my information will be reviewed so I can schedule an intake assessment for medical necessity. I understand minors under the age of 18 must have parent / guardian approval prior to submitting. Upon submission admissions from referral source will contact me. I understand by submitting my information I do not hold Mindcare Today and affilates responsible or guarnatee that I will be admitted into any programming unless based on medical necessity and meet referring organization criteria.

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Find Me A Referral

Please allow up to 24 hours for a referral source to contact you.

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