Referrals | Peace of Mind Mental Health Group

Peace of Mind Mental Health Group

Referral Form

Thank you for referring your patient to Peace of Mind Mental Health Group. Please complete the form below and upload any relevant medical records or supporting documentation. Our intake team will review the referral, match the patient with the best-fit provider, and reach out within 1–2 business days. If you have any questions, please call us at (717) 942-8521.

Please note: This form is not monitored continuously and should not be used for urgent or emergency situations. If the patient is experiencing a mental health emergency or is in immediate danger, call 911, go to the nearest emergency department, or call/text 988 for immediate support.

Referrer Information

Referring Organization

Contact Name

Email Address

Phone Number

Referred Patient Information

Legal Name

Chosen/Preferred Name

Pronouns

Parent/Guardian (if applicable)

Date of Birth

Email address

Phone Number

Address

Insurance Information

Payment Type

Insurance

Self-Pay

Insurance Company

Member ID

Services Requested

Services Requested

Psychiatry/Medication Management

Therapy

Both

Scheduling Preferences

Select all that apply

In-person

Telehealth

Reason for Referral

Presenting concerns, diagnosis, or reason for referral

Upload supporting documents

(Referral/order, medical records, progress notes, psychological or psychiatric evaluations, medication list, insurance card, or other relevant records)

File upload

Authorization & Consent

I have permission to submit this referral and authorize Peace of Mind Mental Health Group to contact the patient regarding services.