Refer a Loved One

A collaborative approach to client care is the most effective treatment. It can be difficult to have a loved one, patient, client, employee, or student who could benefit from starting or additional treatment options.

Refer a Loved One Now

Call (866) 330-8729

I am...

First Name*

Last Name*

Email Address*

Mobile Phone*

Insurance Type*

Age Stage*

Seeking Help For*

Additional Details

SMS Opt In

In providing your mobile number and checking this box, you are consenting to receive SMS (text) messages from Rosecrance Behavioral Health. You may revoke your consent at any time by replying STOP to a message. Message and data rates may apply. Message frequency varies.

Email Opt In

By submitting this form, you are consenting to receive email from Rosecrance Behavioral Health. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe link, found at the bottom of every email.

First Name*

Last Name*

Email Address*

Mobile Phone*

Insurance Type*

Age Stage*

Seeking Help For*

Additional Details

SMS Opt In

In providing your mobile number and checking this box, you are consenting to receive SMS (text) messages from Rosecrance Behavioral Health. You may revoke your consent at any time by replying STOP to a message. Message and data rates may apply. Message frequency varies.

Email Opt In

By submitting this form, you are consenting to receive email from Rosecrance Behavioral Health. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe link, found at the bottom of every email.

Your First Name*

Your Last Name*

Your Email*

Your Phone*

Relationship to the loved one*

Loved One's First Name*

Loved One's Last Name*

Loved One's Email*

Loved One's Mobile Phone*

Loved One's Insurance Type

I Believe They Should Seek Help For*

Description

SMS Opt In

In providing your mobile number and checking this box, you are consenting to receive SMS (text) messages from Rosecrance Behavioral Health. You may revoke your consent at any time by replying STOP to a message. Message and data rates may apply. Message frequency varies.

Email Opt In

By submitting this form, you are consenting to receive email from Rosecrance Behavioral Health. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe link, found at the bottom of every email.

Your First Name*

Your Last Name*

Your Email Address*

Your Mobile Phone Number*

Your Organization*

Client First Name*

Client Last Name *

Client Email*

Client Mobile Phone*

Insurance Type*

Seeking Help For*

Description

SMS Opt In

In providing your mobile number and checking this box, you are consenting to receive SMS (text) messages from Rosecrance Behavioral Health. You may revoke your consent at any time by replying STOP to a message. Message and data rates may apply. Message frequency varies.

Email Opt In

By submitting this form, you are consenting to receive email from Rosecrance Behavioral Health. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe link, found at the bottom of every email.

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