Refer a patient

Thank you for referring to Rogers Behavioral Health. To make the admission process as smooth as possible, please provide the following information on this secure form. Please be assured that this referral will be handled in a way that respects your patient’s privacy and complies with HIPAA regulations. You may also make a referral by calling 800-767-4411 in Southeast Wisconsin or 888-927-2203 for our regional clinics.

We will reach out directly to your client/patient to schedule a screening. If you would like to discuss this referral, please contact your outreach representative. For a complete listing click here.

Have new contact information to share? Please update your credentials and practice information here.

Patient name Required

If patient is under 18, parent or guardian name: Required

Patient phone number Required

Patient email

Referral Provider Name Required

Seeking services for: Required

Addiction

Depression and mood disorders

Eating disorder

OCD and anxiety disorders

Posttraumatic stress disorder

Select the location nearest you. Depending on the needs of the patient, a different location may be recommended. Required

Provider phone number Required

Provider email Required

Your state Required

Relationship with patient

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

Yes

Refer a patient

Treating co-occurring anxiety, mood, and OCD for patients with Autism Spectrum Disorder

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