Start Your Care

Start Your Care

Use this quick self-referral form to begin care at Rumi Mind Health, including both outpatient psychiatry and interventional psychiatry services.
If this an emergency, DO NOT use this form and call 911 instead.

Data from this HIPAA compliant form is not monitored in real-time, and filling out this form does not create a patient-provider relationship.

Please use this form if you are a patient or the caregiver of a patient. If you are a healthcare provider, please use our provider referral form instead.
Are you filling this form on behalf of yourself, or someone else?

MyselfSomeone else
Time

Hour Minutes

AM/PM Option
Your name (the person filling out the form)*

First NameLast Name
Your relationship to the person this application is about:*
On the next page, please provide responses on behalf of the person this application is about.