Stella | Referred Patient Contact Form

Referring_Organization
Owner Id
Record Type
Referring_Practitioner
Country
Source
Subject
Stella Patient Referral
Thank you for trusting Stella with your referral's care and their journey toward healing. Please contact us at referrals@stellamentalhealth.com if you have any questions or trouble completing this form.
I am a

PatientReferring providerReferring organization
Who referred you to Stella?
Your Name/ Organization
Healthcare Provider Referred By
Patient's Name
Your Name
Patient Name
Patient's Email
Your Email
By providing your email address, you agree to receive marketing emails (e.g., information about our services, partner promotions, and new blog content) from Stella.
Email
Do you want to subscribe to emails from Stella?

Yes, I want to receive marketing emails at the email address providedNo
Email Opt Out

TrueFalse
Patient's Phone
Your Phone
Patient Phone
Would you like to also receive texts from Stella with updates and offers (e.g., information about our services and promotions) at the number provided above?*

YesNo
Marketing SMS Opt In

TrueFalse
Patient's State of Residence
Your State of Residence
Your Zip Code
Patient's Date of Birth

MonthDayYear
Date
Your Date of Birth

MonthDayYear
Date
Patient DOB

MonthDayYear
Date
Patient's Gender Identity

FemaleMaleMale-to-Female (MTF)/ Transgender Female/ Trans WomanFemale-to-Male (FTM)/ Transgender Male/ Trans ManGenderqueer, neither exclusively male nor femaleOtherChoose not to disclose
Your Gender Identity

FemaleMaleMale-to-Female (MTF)/ Transgender Female/ Trans WomanFemale-to-Male (FTM)/ Transgender Male/ Trans ManGenderqueer, neither exclusively male nor femaleOtherChoose not to disclose
Patient Gender Identity

FemaleMaleMale-to-Female (MTF)/ Transgender Female/ Trans WomanFemale-to-Male (FTM)/ Transgender Male/ Trans ManGenderqueer, neither exclusively male nor femaleOtherChoose not to disclose
Patient's Sex Assigned at Birth

FemaleMaleOtherUnknownDecline to Specify
Your Sex Assigned at Birth

FemaleMaleOtherUnknownDecline to Specify
Patient Sex

FemaleMaleOtherUnknownDecline to Specify
Which of Stella’s treatments are you interested in? Select all that apply.

Dual Sympathetic Reset (DSR SGB)SpravatoKetamine Infusion TherapyTranscranial Magnetic StimulationIntegration TherapyMedication ManagementI'm not sure
Would you like to send Stella clinical documentation, releases, or other documents related to this referral?

YesNo
After submitting this form, please send documentation to Stella's HIPAA compliant EHR e-fax at 224-538-3267 or contact referrals@stellamentalhealth.com to request a secure file-sharing link.
Additional Details
By entering your email address and subscribing to emails, you consent to receive marketing emails from Stella (e.g. information about our services, partner promotions and new blog content) at the email address you provided.

By entering your phone number and clicking next, you consent to receive marketing (e.g. information about our services, partner promotions and new blog content) and transactional messages (e.g., appointment confirmation and reminders) from Stella at the number you provided. Message frequency varies. Message and data rates may apply. Reply HELP for help. Reply STOP to opt out. View Stella's SMS Terms of Service and Privacy Policy.
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Stella Patient Referral