Download Rosecrance’s Professional Referral Forms

At Rosecrance, we welcome referrals from any medical provider and allied healthcare professional in our quest to help patients and clients embrace their futures and a life of lasting recovery. To facilitate your referrals, below are the various forms you’ll need.

Simply select, download and fill out the most appropriate forms. Feel free to print and complete your forms by hand or fill-out on your computer and then print. Then fax your completed forms to the number on the form. (Your sending fax number will be kept strictly confidential.)

You can also mail your forms. For HIPAA compliance, do not email your referral forms.

If you would like to speak with us directly about a client situation, please call (844) 711-5106 rather than completing and faxing/mailing a referral form.

Chicago Area Referral Form

McHenry High School Referral Form

Rockford Area Referral Form

Wisconsin Referral Form

Rosecrance welcomes hospital referrals

Hospitals looking to refer patients who were treated for withdrawal management are encouraged to fax the applicable referral form above, as well as the required documentation in the list below. The fax number is 815.387.7997.

  • Medication Administration Record (MAR)
  • Provider progress note indicating how the taper will complete
  • Progress notes showing patient’s activity level and how they may be tolerating the taper.
  • Estimated time of the taper
  • Lab results
  • Psychosocial history completed while in the hospital