Patient Referral

We’re here to support you in every step towards a healthier mind.

Pembroke Center for Wellness

Connecting Patients with the Care They Need

Your referrals matter to us! We are committed to making the process easy and efficient. Simply fill out the form below, and we’ll promptly contact the patient to schedule their appointment and provide any additional support required.

Patient Information


Insurance Information

The following insurance information is optional. However, if the patient is not the primary cardholder, please provide the primary subscriber’s name and date of birth to help authorize their plan and process referrals more quickly.

Make sure to include the two numbers at the end (after the hyphen) if applicable.

Your Information

Accepted Insurance Plans

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