Rogers Behavioral Health

Expedited referral form for PHP

Thank you for considering a referral to Rogers Behavioral Health. To make the intake and admission process as smooth as possible for you and your patient, please provide the following information on this secure form. This referral will be handled in a way that respects your patient’s privacy and complies with HIPAA regulations.
A Rogers representative will let you know we received your referral and will follow up with you.

Q&A for Referents

If you do not have information for a required field, please enter "unknown".


Referral form

/ /
You have 2025 characters left.

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

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

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

Clinical Information

Please check YES or NO and provide further info when prompted.

Drag 'n Drop your files here!
Please wait...

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