Submit a Patient Referral Inquiry

Submission of this form represents an inquiry about referring an adolescent or adult patient to Shepherd Center. It is the first step in the online patient referral process, but not a formal referral. For both inpatient and outpatient referrals, Shepherd Center requires the following before the referral process is initiated:

Medical records submitted by the patient’s current healthcare provider or case manager.
Records should be faxed to the Shepherd Center Admissions Department at 404-603-4504.

Once documentation is received, an evaluation may be done to determine if the patient is medically appropriate for Shepherd Center.

Before submitting the form below, please review the patient programs information on the following web pages 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)

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 the form below.

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 are not accepting external referrals at this time. This does not apply to other outpatient services.

Your Relationship to Patient

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 “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.

Injury Type

If other, please describe

Rehabilitation Type

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 Shepherd Center at 404-603-4504.

Referral Information

Patient's 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 Name

Title

Your Phone Number

Your Email Address

Patient Status

Current Patient Location

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

How did you hear about Shepherd Center?

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.