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
Parent/Guardian Information
Parent/Guardian Relationship to Patient
Parent/Guardian Name
Parent/Guardian Email
Parent/Guardian Phone
Format: (000) 000-0000.
Is it ok to leave a voicemail for the parent/guardian above?
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)?
Patient's Name
Your Name
Patient ID
[SF MAPPING] Patient Name
Patient's Email
Your Email
[SF MAPPING] Patient Email
Would you like to receive marketing emails?
[SF MAPPING] Email Opt Out
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.
Patient's Phone
Format: (000) 000-0000.
Your Phone
Format: (000) 000-0000.
[SF MAPPING] Patient Phone
Format: (000) 000-0000.
Would you like to receive marketing texts at this number?
By selecting “Yes,” you agree to receive recurring marketing text messages from Stella Community, including resources, clinic updates, information about our services, and opportunities to connect with care from Stella Mental Health. Message frequency varies. Message and data rates may apply. Reply HELP for help. Reply STOP to opt out at any time. View our SMS Terms of Service and Privacy Policy.
[SF MAPPING] Marketing SMS Opt In
Patient's State of Residence
Your State of Residence
Your Zip Code
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Your Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
[SF MAPPING] Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Patient's Gender Identity
Your Gender Identity
[SF MAPPING] Patient Gender Identity
Your Sex Assigned at Birth
Patient's Sex Assigned at Birth
[SF MAPPING] Patient Sex
Which of Stella’s treatments are you interested in? Select all that apply.
Were you referred to a specific location?
Are you referring the patient to a specific location?
Which California location were you referred to?
Which California location are you referring the patient to?
Which Illinois location were you referred to?
Which Illinois location are you referring the patient to?
Which Massachusetts location were you referred to?
Which Massachusetts location are you referring the patient to?
Which Utah location were you referred to?
Which Utah location are you referring the patient to?
Which location were you referred to?
Which location are you referring the patient to?
DNU -- Were you referred to a specific location?
DNU -- Are you referring the patient to a specific location?
[SF MAPPING] Clinic(s) Referred To
Were you referred to a specific provider?
Are you referring the patient to a specific provider?
Which provider were you referred to?
Which provider are you referring the patient to?
DNU -- Were you referred to a specific provider?
DNU -- Are you referring the patient to a specific provider?
[SF MAPPING] Provider(s) Referred To
Would you like to send Stella clinical documentation, releases, or other documents related to this referral?
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.
Should be Empty:

Stella Patient Referral

Parent/Guardian Information

Your Information

Patient Information

Your Information

Referrer Information