Direct Admissions Request

Patient Name: Required

Date of Birth: Required

Patient Phone: Required

Street Address: Required

City: Required

State: Required

Postal Code: Required

Parent or Guardian Name:

Parent or Guardian Phone:

Insurance provider: Required

Insurance policy ID: Required

How would you recommend your patient receive care?

Level of Care Requested: Required

Preferred Locations: Required

Program Requested: Required

Is this patient currently receiving tube feedings: Required

Please state why the patient needs this program/level of care including current symptoms: Required

Based on this referral, please be aware that Rogers will reach out directly to your patient. Required

I certify that this patient/family is aware of this referral and is not endorsing imminent safety concerns. Required

Referred by: Required

Referent Email: Required

Referent Phone: Required

Attachments available:

Upload additional clinical information: To select multiple files, hold the CTRL key. Max 10MB

Demographics sheet (including insurance information, legal guardian if applicable)
Release of Information (completed and signed/dated)
Most recent Psychiatric/Counseling Assessment (please include information on safety, trauma history, risk of harm to self or others and/or substance use in the past 12 months, where applicable)
Most recent Psycho-Social Assessment (may include ASAM/PPC (patient placement criteria) and/or Individualized Education Plan [IEP], Mobility/Ambulation if applicable or available).
Most recent progress note (or discharge summary, if available)
Eating Disorder Only Additional Needs:

H&P (if available), Current Labs, Vitals, Height, High and low weight trends while in care, Binging/purging practices, EKG, Admitting Labs, Exercise Patterns, Laxative Use, Recent MD & RD progress note, Medication list to include supplements

If complete documentation is not available at this time, please submit the demographic information, ROI, and any relevant clinical notes or supporting materials. Please reach out to elizabeth.edwards@rogersbh.org if you have additional questions.

Direct Admissions Request

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