Provider Referral
Thank you for taking the time to partner with us! We will contact the person you are referring within 24-48 business hours for additional information. If you have any questions regarding the referral process, please call Rex at 608-834-1122 ext. 110
Referring Provider Information
Referring Provider Name and Organization
*
Ex: Dr. John Doe, SSM Health, Madison
Referring Provider Phone Number
*
Email for Submission Confirmation
example@example.com
Client Information
Client Name
*
First Name
Last Name
Is the Client a Minor?
*
Yes
No
If yes, please provide the name of the parent/guardian and the relationship to the client.
E.x.: Jane Doe, mother
Client Phone Number
*
Client Insurance
*
Please Select
None/Self-pay
Aetna
Alliance
BCBS
Care WI
Dean
Humana
Medicaid
Medicare
Quartz
WPS
Other
If Other, please provide the name of the insurance
Referral Services
*
Individual Counseling
Neurofeedback
Healing Hearts Location
*
Delafield
Sun Prairie
Submit
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