Referral portal

Professional referral

Help your patient take the next step.

Complete this brief form together. With the patient’s permission, our referral coordinator will reach out to help arrange an initial consultation.

A personal follow-upOur coordinator contacts the patient directly.

A low-pressure first stepThe consultation helps determine appropriate next steps.

Only essential detailsPlease do not enter diagnoses or clinical notes here.

Questions before referring?Contact Holsoms TMS Mental & Wellness Clinic directly for assistance.

PATIENT CONTACT INFORMATION

Request a consultation

All fields are required. The patient should review and complete the consent section.

Patient permission and signature

I give permission for the contact information on this form to be shared with Holsomstms Mental & Wellness Clinic. I authorize a clinic referral coordinator to contact me by phone, email, or text about scheduling an initial consultation. I understand that this permission is voluntary and does not require me to receive services.

Do not include medical records, diagnoses, or treatment details in this form.