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Peace & Heart Wellness referral

Referral Form

Provider Referral Form

Send secure referrals for patients recovering from injuries or illnesses that impact the nervous system. Our intake nurses coordinate care within two business days and keep your team updated at every step.

Start ReferralIntake Line

Secure fax: 509-495-1166 • Intake desk Monday–Friday 9 AM – 6 PM ET

Secure Form

Provider Referral Form

Complete the form below and our coordination team will reply with appointment options or follow-up questions. For emergent cases, call us after submitting so we can fast-track the evaluation.

Referring Provider

Patient Information

Reason for Referral

Is the patient aware of this referral?
May we contact the patient to schedule?
Urgency of referral
Preferred method for follow-up reports

Secure fax: 509-495-1166 • Intake team available Monday–Friday 9a–6p ET