Submit a Patient Referral Inquiry

Submitting this form initiates a referral inquiry for an adolescent or adult patient to Shepherd Center. It is the first step in the online patient referral process. It is not a formal referral.

Before formally reviewing a referral, Shepherd Center requires the following steps for both inpatient and outpatient referral inquiries.

Patient Referral Process:

Submit the form below, including relevant details about the patient.
Have the patient's current healthcare provider or case manager submit their medical records via the appropriate fax number displayed below.*
Once we receive the patient’s documentation, we may perform an evaluation to determine if the patient is medically appropriate for Shepherd Center.

*If referring to MS, please also fax a referral from the current provider or case manager.

Before submitting the form below, please review our patient programs information to make sure you are submitting an inquiry about the appropriate program.

Spinal Cord Injury Program (inpatient and outpatient services)
Acquired Brain Injury Program (inpatient and outpatient services)
Outpatient Clinics
Shepherd Spine and Pain Institute (outpatient only)
Multiple Sclerosis Institute (outpatient only)
Complex Concussion Clinic (outpatient only)
SHARE Military Initiative (day program and outpatient services)
Beyond Therapy (outpatient only)

Please note that Shepherd Center inpatient rehabilitation programs do not admit inpatients from home. If the patient is currently at home, please inquire about our outpatient services when completing this form.

Also, Shepherd Center does not have contracts with Medicaid programs administered by states other than Georgia. Thus, treatment for patients with out-of-state Medicaid is typically not covered at Shepherd Center.

Due to capacity, Shepherd Center’s day programs for patients with spinal cord injury or brain injury, as well as Shepherd Center's MS Instensive Therapy Progam (ITP), are not accepting external referrals at this time.

The Shepherd Spine and Pain Institute is not taking self-referrals at this time. Please click this provider referral form link for instructions on how your provider can complete the referral process.

Your Relationship to Patient

Please complete the following steps to begin the referral process:

Complete this form, providing as much of the requested information as possible.
Click “Submit Inquiry” to have your message sent to Shepherd Center’s Admissions Department.
Work with your doctor or case manager to complete the referral process.

Condition/Injury Type

If other, please describe

Rehabilitation Type

Records should be faxed to the Shepherd Center Admissions Department at 404-603-4504.

Patient Program

Records should be faxed to the Beyond Therapy program at 404-367-1227.

Records should be faxed to the Complex Concussion Clinic at 404-603-4422.

Records should be faxed to the MS Institute Admissions Department at 404-603-4517 or email MSNewPatientCoordinator@shepherd.org.

Records should be faxed to the Shepherd Center Admissions Department at 404-603-4509.

Records should be faxed to the SHARE Military Initiative Admissions Department at 404-603-4419 or email shareadmissions@shepherd.org.

Records should be faxed to the Spine and Pain Institute at 404-603-4418.

Has a case manager or other healthcare professional submitted a referral for the patient to receive treatment at Shepherd Center?

Please have your case manager or other healthcare professional fax a formal referral submission to the records number indicated above.

Referral Information

Patient's First Name

Patient's Last Name

Patient's Date of Birth (DOB)

MM/DD/YYYY

Patient's Date of Injury/Onset of Illness

Patient's Phone Number

Patient's Email Address

Your Information

Your First Name

Your Last Name

Title

Your Phone Number

Your Email Address

Patient Status

Current Patient Location

What facility is the patient in?

Country

Which country?

State or Province

State

City

Patient Information

Referring Provider

Referring Provider Name

Mailing Address

Email Address

Phone Number

Additional Information

Insurance

How did you hear about Shepherd Center?

Please fax the patient’s medical records to Shepherd Center via the program numbers listed below:

Spinal Cord Injury (inpatient) at 404-603-4504
Spinal Cord Injury (outpatient) at 404-603-4509
Brain Injury (inpatient) at 404-603-4504
Brain Injury (outpatient) at 404-603-4509
Complex Concussion Clinic (outpatient only) at 404-603-4422
MS Institute (outpatient only) at 404-603-4517
Spine and Pain Institute (outpatient only) at 404-603-4418
Beyond Therapy (outpatient only) at 404-367-1227
SHARE Military Initiative (outpatient only) at 404-603-4419

Download this PDF file to get a checklist of additional information needed for the referral process.