You are here: Home Admissions Refer a Patient Page Content Refer a Patient Your Relationship to Patient Select One Family Member Friend Advocate Healthcare Professional Other Please complete the following steps to begin the referral process for your loved one: Complete this form, providing as much of the requested information as possible. Click “Request Referral” to have your message sent to Shepherd Center’s Admissions Department. Work with your doctor or case manager to complete the referral process. Injury Type Select One Spinal Cord Injury Acquired Brain Injury Stroke Other If other, please describe Rehabilitation Type Select One 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? Select One 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 Select One 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 Select One Commercial (e.g., Cigna, Aetna, Blue Cross/Blue Shield) Medicare Medicaid None Self-Pay Workers' Compensation How did you hear about Shepherd Center? Select One 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.
