CONTACT US
Referring a patient can be completed via eFax by sending it to 630-874-0986. If you have any additional questions, please call us at 630-620-4433.
Patient Name
*
First Name
Last Name
DOB
example@example.com
Caregiver Name
*
First Name
Last Name
Caregiver Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Type of Insurance
Medicaid, PPO, HMO, Self-Pay or Other
Referring Provider Name
First Name
Last Name
Practice Name:
Practice Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician or Referrer Phone Number:
*
Please enter a valid phone number.
Which service are you referring this patient to?
*
Occupational Therapy
Speech-Language Therapy
Physical Therapy
Nutrition
Mental Health
Audiology
Medical Diagnostic Clinic
Autism Diagnostic Clinic
Feeding Clinic
Intensive Therapy
Bowel & Bladder Clinic
Respiratory Clinic
Other
Which location is preferred for this patient?
*
Villa Park
Naperville
Elgin
Tele-Therapy
Early Intervention
Identify Chief Compaint(s)
Pertinent and Quick Patient History (1-2 sentences):
Do you have any questions for an Easterseals clinician?
Please share your inquiry and you will receive a response within two business days.
How did you hear about us?
Current Referrer
Other Healthcare Contact
Internet Search
Social Media
Other
Additional Privacy Information
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*
SUBMIT
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