Provider-to-Provider Referral

Refer a patient to our PMHNP.

Use this form to refer a patient to Yvonne Amune, PMHNP-BC for psychiatric evaluation, medication management, or integrated mental-health support. We accept referrals from primary-care physicians, therapists, social workers, and other licensed clinicians in Texas.

HIPAA minimum-necessary: please send only patient initials and the brief reason for referral. The patient will fill out their own full intake when we contact them.

Your information

Provider name *NPI (optional)Practice / clinicEmail *Phone

Patient (minimum-necessary)

Patient initials *Date of birth (optional)Patient phone (optional)Patient email (optional)

Reason for referral *Urgency

* I am the patient's authorized treating clinician (or designee) and have a treatment relationship that permits this referral under 45 CFR § 164.506.

Submissions transit TLS-1.2+ and are stored under our HIPAA security posture. If you'd prefer fax, send to .