You are here: Home Admissions For Healthcare Professionals Refer a Patient Page Content Refer a Patient Please complete the form below, providing as much of the requested information as possible. When finished, click on "Request Referral" to have your message sent to Shepherd Center's Admissions Department. Your Relationship to Patient Family Member Friend Advocate Healthcare Professional Other Injury Type Spinal Cord Injury Acquired Brain Injury Stroke Other If other, please describe Rehabilitation Type Inpatient Outpatient SHARE Military Initiative Multiple Sclerosis Institute Spine and Pain Institute Complex Concussion Clinic Has a case manager or other healthcare professional submitted a referral for the patient to receive treatment at Shepherd Center? -- No Yes Please have your case manager or other healthcare professional fax a formal referral submission to Shepherd Center at 404-603-4504. Referral Information Patient's Name Patient's Date of Birth (DOB) MM/DD/YYYY Your Information Your Name Title Your Phone Number Your Email Address Patient Status Current Patient Location Home Healthcare Facility Other What facility is the patient in? City State or Province Country Patient Information Referring Provider Referring Provider Name Mailing Address Email Address Phone Number Additional Information Insurance Commercial (e.g., Cigna, Aetna, Blue Cross/Blue Shield) Medicare Medicaid None Self-Pay Workers' Compensation How did you hear about Shepherd Center? --- Internet search Friend or family Healthcare professional Other Please fax the patient’s medical records to Shepherd Center at 404-603-4504. Download this PDF file to get a checklist of additional information needed for the referral process.