Make a Referral

Submit our Make a Referral form! Please complete the form for consideration of an individual who would benefit our services. Review all the necessary information to gather outstanding details for submission.

Client Referral Information

Instructions: To make a Client Referral to Altum Care Homes Rehabilitation Services please fill out the form below with your information. A member of our Rehabilitation Services Staff will be in touch with you before the end of the next business day. 

Type in individual's name you are referring to Altum Care Homes.

Include address of client you are referring.

Client Referral Email Address goes here

Include phone number where Referred Person can be reached

Include the date of birth of the person being referred.

Please include your relationship to the individual

Include a contact number for follow up of Client Referral.

Primary Insurance of Client Being Referred

Auto Insurance
Health Insurance (i.e., BCBS, Priority Health, Aetna)
Private Pay
Other

Secondary Insurance of Client Being Referred

Auto Insurance
Health Insurance (i.e., BCBS, Priority Health, Aetna)
Workers Compensation
Private Pay
Other
N/A
Inpatient Rehabilitation
Residential (Long-Term/Community-Based)
Outpatient Therapy
Vocational Rehabilitation
Other