Referral to IJR

The doctors and staff at the Colbeth Child and Adolescent Psychiatric Clinic strive to provide the highest quality of medical services for the children entrusted to their care. To refer a child to one of our specialty clinics, fill out and submit the form below or contact our Outreach Team at (312) 996-7723. They will explain everything you need to know to begin arranging for care when appropriate.

Fill out and submit the secure referral form below to begin the transfer process. After you submit this form, you will receive a phone response within 24 hours, excluding weekends and holidays.

Patient Referral Form

 

Patient Information   Referring Physician
         
First Name:   First Name:
Last Name:   Last Name:
Date of Birth:   Admin Contact:
If patient is under 18, provide parent or guardian name      
  E-mail:
Insurance Provider:   Confirm E-mail:
         
Address 1:   Address 1:
Address 2:   Address 2:
City:   City:
ST/Zip:   ST/Zip:
         
Primary Phone:   Primary Phone:
Alternate Phone:   Fax:
         
Reason for Referral:        
Comments:        

 

Press the SEND button to submit this form electronically. This and other forms may also be printed out and faxed to our Scheduling Center. Our fax number is (312) 413-7757.