Provider Referral Form
Magnolia Wellness & Psychology is happy to partner with mental health providers (e.g., counselors, therapists, psychologists, coaches, behavioral analysts, etc. ), speech, occupational, and physical therapists, medical providers (e.g., primary care, pediatricians, psychiatrists, nurse practitioners, etc.), organizations, and others who meet the overall health needs of children and adults with Autism, ADHD, and/or Learning Disabilities.

If you are interested in joining our provider referral network, please complete the form below.

If you are interested in speaking more with us about our services or how we might partner to serve our communities, please schedule directly in the google calendar in the open appointment slot at https://calendar.google.com/calendar/u/1?cid=dHNlZHdhcmRzQG13cHN5Y2hvbG9neS5jb20, email us at info@mwpsychology.com, or give us a call at 678-824-7733.

If you would like to refer your clients here, please complete the form below with your details and the client's name and best contact information.  We are happy to answer any questions you may have at our general email at info@mwpsychology.com or at our practice line 678-824-7733.

Thank you so much for your continued support of our business!
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Provider, Practice, or Agency Name *
Email *
Phone Number
Website URL
Are you referring anyone to us? *
If yes, please provide client's first name, last initial
Is this client a minor (under 18)?
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If client is a minor, please provide their parent/guardian's name. (first name and last initial)
Client's Contact Information (email, phone number, or both)
Please describe the concerns leading to your referral and, if you know already, what type of evaluation they may need.
Are there any additional questions, concerns, etc. that we need to address or be aware of when meeting with this client? (n/a if no)
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