Please Enter Patient Referral Data Here -

In order to help, we will need to get the patient information. Please obtain their permission to share the information before providing it here. They may opt-out at any time.

This is Part II of your Patient Referral Process. Please share patient information below, with their permission, and we will immediately begin communicating with them. They may opt out of our communication at any time.

Referring Clinician Information

Name of Referring Clinician (please reenter)

Referral Source Email for us to communicate with you about the patient (please reenter) *

How Can We Help?

Patient Referral Information (fields with * are required)

Patient Name *

Phone *

Email *

Select the Insurance Provider *

If you would like to refer to a specific physician or clinician, please select from this drop down or leave blank for first available:

(We do not take Tenncare)

Interest *

TMS - Transcranial Magnetic Stimulation

Esketamine (Spravato) or Ketamine

Prism Self-Neuromodulation Treatment

Telehealth ONLY (Medication Management and/or Therapy) - you must be in Tennessee to receive care.

Evaluation for Diagnosis & Treatment with a Prescriber

Therapy Only (not yet available in our Memphis location)

Therapy & Medication Management

Team Evaluation - Med Mgmt &/or Therapy (not yet available in our Memphis location)

As the referring clinic or clinician, I acknowledge and agree that I have received permission from the patient to enter their contact information. The patient understands they will receive texts, emails and calls from us in the process of getting them scheduled, and they may be required to fill out forms or pay co-pays or deposits to be seen. The patient still agrees to this referral. The patient may terminate communication from us at anytime if they do not want to move forward with scheduling.