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Life Balance
Life BalanceCasey Hester, PMHNP-BC

For Providers

Refer a Patient

Submit a referral electronically, fax the printable form, or call the office. We'll fax documentation back after the patient is seen.

Electronic Referral Form

Fields marked required are needed to process the referral.

Referring Provider
Patient
Reason for Referral
Call OfficeEmail Directly

This form submits your referral directly to the office. For PHI-sensitive documentation, please fax to 662-238-4122 or use a HIPAA-compliant secure channel.