Refer a patient for residential care

To make the intake and admission process as smooth as possible for you and your patient, please call 800-767-4411. This referral will be handled in a way that respects your patient’s privacy and complies with HIPAA regulations.

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

 

Patient name: Required

If patient is under 18, parent or guardian name:

Patient phone number: Required

Patient email: Required

Primary Language: Required --None-- English Spanish Abkhaz Adyghe Afrikaans Akan Albanian American Sign Language Amharic Ancient Greek Arabic Aragonese Aramaic Armenian Aymara Balinese Basque Betawi Bosnian Breton Bulgarian Cantonese Catalan Cherokee Chickasaw Chinese Coptic Cornish Corsican Crimean Tatar Croatian Czech Danish Dawro Dutch Esperanto Estonian Ewe Fiji Hindi Filipino Finnish French Galician Georgian German Greek, Modern Greenlandic Haitian Creole Hawaiian Hebrew Hindi Hungarian Icelandic Indonesian Interlingua Inuktitut Irish Italian Japanese Javanese Kabardian Kalasha Kannada Kashubian Khmer Kinyarwanda Korean Kurdish/Kurdî Ladin Latgalian Latin Lingala Livonian Lojban Lower Sorbian Low German Macedonian Malay Malayalam Mandarin Manx Maori Mauritian Creole Middle Low German Min Nan Mongolian Norwegian Oriya Pangasinan Papiamentu Pashto Persian Pitjantjatjara Polish Portuguese Proto-Slavic Quenya Rapa Nui Romanian Russian Sanskrit Scots Scottish Gaelic Serbian Serbo-Croatian Sinhalese Slovak Slovene Swahili Swedish Tagalog Tajik Tamil Tarantino Telugu Thai Tok Pisin Turkish Twi Ukrainian Upper Sorbian Urdu Uzbek Venetian Vietnamese Vilamovian Volapük Võro Welsh Xhosa Yiddish Zazaki

Interpreter requested:

Referral Provider Name: Required

Seeking services for: Required --None--Addiction Depression and mood disorders Eating disorder OCD and anxiety disorders Posttraumatic stress disorder

Where is the patient seeking treatment? Required --None--Oconomowoc West Allis Brown Deer

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

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

Provider phone number: Required

Provider email: Required

Your state: Required --None--Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming

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

Notes:

Upload additional clinical information or insurance card:

Attachments available: