To make a referral to our office for testing or counseling,

please fill out the form below and press "SUBMIT":

Please fax any medical records or documents that accompany this referral to our office manager Kathy at 765-252-1316.

Any line below with an * indicates a required field. Your referral will NOT submit to our office if you have not filled out all REQUIRED* fields.

Please provide as much information as possible so we can complete your referral without delay.

Referral Source Phone Number
Referral Source Phone Number
Referral Source Fax Number *
Referral Source Fax Number
FOR TESTING REFERRALS: You MUST include the accurate fax number for where you want the final testing report to be faxed.
Patient Name *
Patient Name
Patient DOB *
Patient DOB
Contact Phone Number *
Contact Phone Number
Alternate Contact Phone
Alternate Contact Phone
Services Requested *
Testing to rule out:
(check as many as needed)



1806 W. Royale Dr.

Muncie, IN 47304

Phone Numbers:


765-252-1316 (fax)