Expedited Referral Pathway for Colleges & Universities

Thank you for thinking of The Renfrew Center for your student. To facilitate a smooth and efficient referral process for you, we have outlined the necessary information required to ensure your student receives the appropriate care in a timely manner. Our goal is to make this as quick and seamless as possible, allowing you to easily provide the needed details.

Below is a list of required documentation and forms to help expedite the referral and admission. Should you have any questions or require assistance at any stage, Shelby Harcher, Program Information Manager, is here to support you every step of the way and can be reached at [email protected].

You can also contact our National College Liaison, Lauren Pendleton at [email protected] or 980-406-0151.

We appreciate your partnership and look forward to working together to provide the best possible care for your student.

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Patient Information

Name *

First Name Last Name

Student Phone *

Student Email *

College/University *

Date of Birth (DOB): *

Location *

City State ZIP Code

Is the student aware of this referral? *

Yes

Referral Information:

Staff Member Making Referral

First Name Last Name

Staff Member Phone

Staff Member Email

Reason For Referral

Preferred Method of Contact

Best Time to Contact You

Insurance Information:

This section is optional.

Insurance Provider Name

Policy Holder Full Name

First Name Last Name

Policy Holder’s Date of Birth

Relationship to Student

Policy Number

Group Number

Insurance Provider’s Phone Number

Type of Plan

Clinical and Medical Information:

Please fax the following documents to 215-482-5463. While these documents aren’t required to be submitted now, sharing them can help ensure a smoother referral process for your student.

Biopsychosocial Evaluation
Current Height/Weight/Vitals
Medical Office Visit Notes
Lab and Test Results (including EKG)

Next steps: Renfrew’s Program Information Department will be in touch with the referred student to schedule an assessment as well as follow up with you as their referral source.

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Reach Out to Us

Call 1-800-RENFREW (736-3739)

Talk with a Program Information Specialist at the number above to learn more about our
services and to schedule an assessment. Or, fill out the information below and we will contact you.