For referring providers

Provider referral form.

Send us a patient referral and securely upload their most recent progress notes and insurance information. We'll follow up with your office and the patient.

Schedule an appointment (601) 494-5503

Referring provider

Your name (required)Credentials (MD, NP, LPC…)

Medical facility / practice (required)

Office phone (required)Office fax

Your email

How did you hear about us?

Patient information

Patient first name (required)Patient last name (required)Date of birth Patient phone Patient email Insurance carrier

UrgencyReason for referralAdditional notes

Secure uploads

PDF, image, or document files up to 15 MB each (up to 5 files per section). Files are stored privately and are only visible to our staff.

Most recent progress notesPatient insurance information

Please confirm you have the patient’s authorization to share this information. This form is not for emergencies.

Ready when you are

Questions about a referral?

Call (601) 494-5503 or email info@turnedleafpsychiatry.com and our team will help.

Schedule an appointment (601) 494-5503