Submit an Admissions Inquiry to Shepherd Center

Please note: This is not an official referral.

This form initiates the process of an admission inquiry with Shepherd Center, enabling healthcare providers to assess if our rehabilitation services align with their patient's needs.

For discussions regarding patient suitability, please call 404-350-7367. Referrals can be faxed to the Shepherd Center Admissions Department at 404-603-4504 or submitted directly through an online referral system such as CarePort or Ensocare.

Asterisk (*) indicates required.

Healthcare Professional Information

First Name

Last Name

Phone Number

Email Address

Position

Other, please specify:

Healthcare Facility

Patient Information

Patient First Name

Patient Last Name

Patient's Date of Birth

What is the patient's current location?

Name of Facility

Please Note: Shepherd Center does not admit inpatients directly from home. If your patient is currently at home, we encourage them to explore our outpatient services.

Other, please specify:

Is the patient presently located in the United States?

City

State

Country

City

State or Province

Other, please specify:

Patient's Date of Injury/Onset of Illness

Patient's Primary Insurance Provider

Please Note: Shepherd Center does not have contracts with Medicaid programs administered by states other than Georgia. Thus, treatment for patients with out-of-state medicaid is typically not covered at Shepherd Center without a single case agreement.

None of the above, please specify:

Questions or additional information you'd like to provide

How did you hear about Shepherd Center?

Other, please explain:

Contact Information