Why we do this:

• Security: It validates your identity as a provider and keeps the referral process HIPAA-compliant.

• Convenience: If you are interrupted, this allows you to return and complete the form exactly where you left off.

• Privacy: Your contact information is used strictly for this authentication step and will not be stored for marketing purposes.

Thank you for partnering with Mindful Mobility to improve driver safety and independence.

Professional Referrals

This page is designed for healthcare providers looking to initiate a driving rehabilitation or occupational therapy evaluation with Mindful Mobility.

Our goal is to streamline the referral process, ensuring that all necessary clinical information is captured securely so we can begin supporting the driver's independence as quickly as possible.

How to Refer a Patient

Please choose the method that best fits your office workflow. Both options are secure and HIPAA-compliant.

Option 1: Digital Submission (preferred)

Option 2: Manual Submission

To expedite the evaluation process, please fax this form along with recent medical records and diagnostic notes to (833) 523-2388.

Note: To protect the privacy of our patients and ensure a secure connection, our referral portal requires a quick identity verification. When you click the link above, you will be asked to enter your email or phone number to receive a one-time confirmation code.