Refer a Patient

Submit a referral below. We respond to all referrals within one business day and provide loop-close confirmation after the initial evaluation.

Augustine Mensah, MSN, BSPH, APRN, PMHNP-BC · Psychiatric Nurse Practitioner · Worcester, MA

Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Patient Phone Number*

Patient Email

Best Time to Reach Patient

Does the patient consent to being contacted by Aura Integra?*

Yes No

Primary Reason for Referral*

Urgency*

Current Medications

Relevant Clinical Notes

Is Patient Currently in Crisis?

Yes No

Your Name*

Your Title / Role*

Organization / Practice Name*

Phone Number*

Email Address*

Would you like a loop-close confirmation after the intake?

Yes No

This form transmits information over an encrypted connection. For emergencies, call 911. For crisis support, call or text 988.