Stella | Referred Patient Contact Form

Referring_Organization
Referring_Practitioner
Owner Id
Record Type
Country
Source
Subject
Stella Patient Referral
Thank you for trusting Stella Mental Health with this referral. We know that seeking care – for yourself or someone you care about – can feel overwhelming, and our team is here to make the process as clear, supportive, and seamless as possible.

This form helps us gather the information we need to update our records and move your referral efficiently through our intake process, with minimal administrative burden. If you have questions at any point or need help completing this form, please reach out to us at referrals@stellamentalhealth.com – we’re happy to help.

If this is an emergency or crisis situation, please call 911 or go to your nearest emergency department. You can also call or text 988 to reach the Suicide & Crisis Lifeline for immediate, confidential support.
I am a

Potential patientParent/ guardian of a potential patientReferring providerReferring organization
Parent/Guardian Information
Parent/Guardian Relationship to Patient
Parent/Guardian Name
Parent/Guardian Email
Parent/Guardian Phone
Is it ok to leave a voicemail for the parent/guardian above?

YesNo
Your Information
Your Name
How can we get in touch with you? Please share your phone and/or email address.
Role
Organization
Your Zip Code
Please share the ZIP code of your practice or organization.
Healthcare Provider Referred By
Patient Information
Your Information
Is this potential patient a minor (less than 18 years old)?

YesNo
Patient's Name
Your Name
[SF MAPPING] Patient Name
Patient's Email
Your Email
[SF MAPPING] Patient Email
Would you like to receive marketing emails (e.g., information about our services, partner promotions, and new blog content) from Stella at the email address provided?

YesNo
[SF MAPPING] Email Opt Out

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

YesNo
[SF MAPPING] Marketing SMS Opt In

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

MonthDayYear
Your Date of Birth

MonthDayYear
[SF MAPPING] Patient DOB

MonthDayYear
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
[SF MAPPING] 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
Your Sex Assigned at Birth

FemaleMaleOtherUnknownDecline to Specify
Patient's Sex Assigned at Birth

FemaleMaleOtherUnknownDecline to Specify
[SF MAPPING] 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
Please do not disclose any personal, health, or trauma details in this space. Please only share pertinent details related to funding, billing, and/or contact preferences if applicable.
Referrer Information
What is the name of the individual or group who referred you to Stella?
How can we get in touch with them? Please share their phone and/or email address.
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.
Should be Empty:

Stella Patient Referral

Parent/Guardian Information

Your Information

Patient Information

Your Information

Referrer Information