Refer Patients to KMH | Kellen Mental Health

Our team is committed to working with you to ensure your patient receives the highest quality care.

Please complete this form and we will reach out to your patient within 24 hours. We will notify you as soon as we make contact.

If you have any questions, feel free to email us at contact@holisticwellnesspractice.com or call us at: (470) 231-5355

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Parent / Guardian Full Name(Required)

Parent / Guardian Phone #(Required)

Parent / Guardian Email Address(Required)

Patient Full Name(Required)

Patient DOB(Required)

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Patient Phone #(Required)

Patient Email Address(Required)

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Referral Source Name (Provider or Agency)(Required)

Referral Source Phone Number (Provider or Agency)(Required)

Notes for Referral(Required)