Expedited referral form for Rogers Behavioral Health in Nashville

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

 

Referral form

Required
Required
Required
Required
Required
Required
Required
Required
Address
Required

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

Required
Required
Required
Required
Required
Required

Clinical Information

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

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