Send what you have. MindVibe intake can take it from there.

Upload an existing referral packet, type a quick referral, or do both. The form is built for provider offices, therapists, carriers, employers, and referral partners who need a clean psychiatry handoff.

Referral route: General Referral

What are you referring for?

General PsychiatryEvaluation, medication management, telepsychiatry, or in-clinic psychiatry.Spravato Treatment EvaluationTreatment evaluation for appropriate depression referrals while keeping the referring provider connected.

Upload existing referral packetBest when you already have a chart note, referral sheet, ROI, or insurance packet.Enter quick referralBest when you only need to send the basics and let intake follow up.

Prefer to fax? Send referral packets to (805) 439-1070 (click to copy the number). Faxed referrals go to the same intake team.

Upload existing referral packet

Already have a referral sheet, chart note, ROI, medication list, insurance card, or lab packet? Upload it here.

Upload files

No files selected

PDF, image, Word, or text files. Current limit: 25 MB per file, 100 MB total packet.

Referral contact

Who should MindVibe contact for questions and confirmation?

Organization or practiceOffice contact name *Contact phoneContact emailReferring providerRelationship to patient/source

A phone or email is required so intake can confirm receipt.

Patient basics

Add enough detail for intake to identify and reach the patient.

Patient first namePatient last nameDate of birthPatient phonePatient email

Reason for referral

One short note is enough to get the referral moving.

Reason for referralUrgencyPatient aware of referral?

Optional insurance and authorization

Add this if it is already in front of you.

Insurance planMember IDGroup numberPolicyholder nameRelationship to patientAuthorization required?Authorization numberSelf-pay if needed?

Spravato treatment details

Helpful for Spravato referrals, especially when another mental health provider remains involved.

Current mental health providerCare coordination preferenceDiagnosis or presenting depression concernPrior medication trials or treatment historyInsurance authorization started?

Optional patient details

Helpful, but not a reason to delay the referral.

Preferred contactInterpreter needed?Language, if applicableGuardian name, if minorGuardian phonePatient address

Optional provider details

Useful for outreach and follow-up when available.

SpecialtyNPIOffice faxOffice address

Optional clinical details

Add clinical context only if it is readily available.

Submit referral

The referring contact receives a confirmation email. MindVibe intake receives the referral details and attachments when secure email is configured.

I am authorized to submit this referral and share the attached information with MindVibe for treatment, payment, or healthcare operations.

If the patient is in immediate danger or may need emergency care, call 911 or 988. Do not rely on this web referral for emergencies.

Questions before submitting? Call (833) 836-2290fax (805) 439-1070email referral@mindvibe.com.