Stella | Referred Patient Contact Form

  • 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

  • Format: (000) 000-0000.
  • Is it ok to leave a voicemail for the parent/guardian above?

  • Your Information

  • Patient Information

  • Your Information

  • Is this potential patient a minor (less than 18 years old)?
  • 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?
  • [SF MAPPING] Email Opt Out
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 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?*
  • [SF MAPPING] Marketing SMS Opt In
  • Patient's Date of Birth
     - -
  • Your Date of Birth
     - -
  • [SF MAPPING] Patient DOB
     - -
  • 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.
  • 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. 

  • Referrer Information

  • 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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