Refer a Patient
Share your contact details to start a referral conversation. Do not include protected health information or detailed medical records.
Important Privacy & Emergency Notice
Do not submit emergency requests or highly sensitive medical information through this form. Our team will provide instructions for secure document transmission. If this is a medical emergency, call 911.
Preliminary Referral Inquiry
What Happens Next
Share Your Contact Details
Tell us who you are, how to reach you, and which service the patient may need. No protected health information is required at this stage.
Our Intake Team Contacts You
Our intake team reviews your inquiry and reaches out to discuss the referral and answer your questions.
Secure Information Transfer
We provide instructions for securely transmitting clinical documents, so patient information never travels through this form.
Referral by Phone
Speak directly with our intake coordination team to discuss a complex case or initiate a referral.
(312) 224-2444Future Ready
A secure provider portal is in development, allowing for direct EHR integration, status tracking, and secure document upload.