Refer a patient

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. 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 call us at 800-767-4411.

A Rogers representative will let you know we received your referral and will follow up with you and your patient within one business day.

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

Seeking services for: Required

Addiction

Depression and mood disorders

Eating disorder

OCD and anxiety disorders

Posttraumatic stress disorder

Referring provider name 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

Theresa shares why multiple levels of care were critical to her recovery

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