Provider Referral

Secure, comprehensive psychiatric referral options for your patients.

Thank You for Your Referral

We’re committed to providing a streamlined, HIPAA-compliant referral experience—ensuring your patients receive attentive psychiatric care tailored to their unique needs. Please select from our secure electronic referral form or alternative upload/fax methods.

Comprehensive Referral Form

Fill out the form below to securely send patient information. All data is transmitted via our HIPAA-compliant solution.

Referring Provider Name Practice / Clinic Name

Provider Contact (Phone / Email)

Provider NPI (If applicable)

Patient Information

Patient Name

Date of Birth

Patient Contact Number Primary Insurance / ID (If known)

Reason for Referral & Clinical Details

Reason for Referral / Chief Complaint Relevant Past Psychiatric / Medical History Current Medications (including dose/frequency) Additional Comments Upload Attachments (Optional)

Disclaimer: Please ensure you only submit Protected Health Information (PHI) through this HIPAA-compliant form or via secure channels (e.g., Spruce, Osmind). For urgent or emergency concerns, contact local emergency services or call 911.

Secure Portal Upload

Already have a Spruce or Osmind account with us? Log in to securely upload referral documents. This ensures direct, encrypted transmission of patient data.

Access Secure Portal

Fax Referral

Prefer fax? Please send completed referral forms to:
Fax: (309) 204-8259

We’ll confirm receipt and reach out to the patient promptly to schedule their initial visit.

If you have questions about our referral process or services, please contact us at (309) 245-7115 or info@gravitypsychiatrywellness.com.