Refer a patient

To make the intake and admission process as smooth as possible for you and your patient, please call 800-767-4411. This referral will be handled in a way that respects your patient’s privacy and complies with HIPAA regulations.

We will reach out directly to your client/patient to conduct their screening. If you would like to discuss this referral, please contact your community relations liaison. For a complete listing click here.  

 

Patient not at imminent risk of harm: Required: (please check box to approve)

Based on this referral, please be aware that Rogers will reach out directly to your patient. Required: (please check box to approve)

Referral form completed by: Required

Referring provider name: Required

Company: Required

Provider phone number: Required

Provider email: Required

Patient name: Required

Date of birth: Required

Street address: Required

City: Required

State: Required --None--Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming

Postal Code: Required

Country: Required

Patient phone number: Required

Ok to leave voicemail: Required --None--Yes No

Parent or Guardian Name:

Parent or Guardian Phone:

Ok to leave voicemail with parent/guardian: --None--Yes No

Primary Language: Required --None--English Spanish Declined to Specify or Unknown Abkhaz Adyghe Afrikaans Akan Albanian American Sign Language Amharic Ancient Greek Arabic Aragonese Aramaic Armenian Aymara Balinese Basque Betawi Bosnian Breton Bulgarian Cantonese Catalan Cherokee Chickasaw Chinese Coptic Cornish Corsican Crimean Tatar Croatian Czech Danish Dawro Dutch Esperanto Estonian Ewe Fiji Hindi Filipino Finnish French Galician Georgian German Greek, Modern Greenlandic Haitian Creole Hawaiian Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Inuktitut Irish Italian Japanese Javanese Kabardian Kalasha Kannada Kashubian Khmer Kinyarwanda Korean Kurdish/Kurdî Ladin Latgalian Latin Lingala Livonian Lojban Lower Sorbian Low German Macedonian Malay Malayalam Mandarin Manx Maori Mauritian Creole Middle Low German Min Nan Mongolian Norwegian Oriya Pangasinan Papiamentu Pashto Persian Pitjantjatjara Polish Portuguese Proto-Slavic Quenya Rapa Nui Romanian Russian Sanskrit Scots Scottish Gaelic Serbian Serbo-Croatian Sinhalese Slovak Slovene Swahili Swedish Tagalog Tajik Tamil Tarantino Telugu Thai Tok Pisin Turkish Twi Ukrainian Upper Sorbian Urdu Uzbek Venetian Vietnamese Vilamovian Volapük Võro Welsh Xhosa Yiddish Zazaki

Interpreter requested: Required

Insurance provider:

Insurance policy ID:

Where is the patient seeking treatment? Required Appleton Atlanta Brown Deer Denver Hinsdale Kenosha Los Angeles Madison Manitowoc Miami Minneapolis Nashville Oconomowoc Philadelphia San Diego San Francisco East Bay Seattle Sheboygan Skokie St. Paul Tampa Wausau West Allis

How would you recommend your patient receive care? --None-- My patient is best suited for care in person. My patient is best suited for care virtually, if available. My patient would do well in either setting and is open to first available option.

My patient is interested in Psychiatric outpatient care only (includes psychiatric evaluations and medication management):

My patient is interested in TMS (available in West Allis, WI):

Reason for Referral: (maximum 3,000 characters) Required

Upload additional clinical information or insurance card:

Attachments available: