Download Rosecrance’s Professional Referral Forms

At Rosecrance, we welcome referrals from any medical provider and allied healthcare professional in our quest to help patients and clients embrace their futures and a life of lasting recovery. To facilitate your referrals, below are the various forms you’ll need.

Simply select, download and fill out the most appropriate forms. Feel free to print and complete your forms by hand or fill-out on your computer and then print. Then fax your completed forms to the number on the form. (Your sending fax number will be kept strictly confidential.)

You can also mail your forms. For HIPAA compliance, do not email your referral forms.

If your patient or client has an emergency situation, please call 888-928-5278 rather than completing and faxing/mailing a referral form.

Chicago Area Referral Form

McHenry High School Referral Form

Rockford Area Referral Form

Wisconsin Referral Form