Expedited referral form

Referral form

Are you a licensed provider? (therapist, psychiatrist, PCP, etc.) Required

Yes

Referring provider name Required

Provider phone number Required

Provider email

Patient name Required

Date of birth Required

/ /

You have 2025 characters left.

Gender Required

Primary phone number Required

Ok to leave voicemail? Required

Yes

Patient email

If contact information provided is not for patient themselves, what is their relationship to the patient

Primary language Required

Address Required

Insurance information

Please enter the patient’s insurance information below, or upload an image of their insurance card at the end of this form. If patient is self-pay or information is unknown, please enter that below.

We are unable to accept Medicaid, Medicare, and Tricare plans

What is the name of the insurance provider? Required

Insurance policyholder Required

Insurance policy ID Required

Insurance phone number Required

Parent/guardian name

Parent/guardian phone number

Ok to leave voicemail?

Yes

If the patient is 10 or under, is the parent/guardian willing to participate in and attend treatment, if deemed appropriate by the treatment team?

Yes

Is the patient able to attend treatment daily (M-F) for the recommended length of stay? Required

Yes

Is the patient currently in the ER or in an inpatient or residential facility? Required

Yes

Treatment in each program may vary up to 12 weeks; - 6.5 hours daily for PHP

Where is the patient seeking treatment? Required

What program are you recommending for this patient? Required

Programming differs by location. For a complete list of program offerings by location, visit our program directory.

Please list all psychiatrist diagnoses (list names starting with primary) Required

Expedited referral form for PHP

Referral form

Insurance information

Clinical Information

Call 800-767-4411 or go to rogersbh.org to request a free screening.