Note: to ensure secure, HIPAA-compliant transmission of confidential clinical records,
please complete this fillable form, send via secure eFax to 253-639-7145
Or by US mail to: MindSource Center, LLC, 27023 164th Ave SE, Covington, WA 98042

Provider Referral Form

Provider Referral Form

Patient Information
Drop files here or
Max. file size: 300 MB.