PATCH Provider Referral Form

Thank you for your interest in referring your patient to PATCH (Patient Assistance Team at Children’s Hospital & Medical Center). Please submit this HIPAA compliant form and a member of our Child Live Services team will reach out to the parent/guardian to create the Adaptive Care Plan. We will also keep you informed of the status of the referral.

Patient Information
Patient's Name*

First

Last
Date of Birth*

MM slash DD slash YYYY
Children’s Hospital MR# (if available)
Parent/Caregiver Name*

First

Last
Parent/Caregiver Phone*
Parent/Caregiver Email
Referring Physician/Practitioner Information
Name*

First

Last
Phone*
Email
Clinic Name*
Referral Information
Does the patient have autism spectrum disorder?*
- Yes
- No
- Suspected, but not confirmed
Does the patient have a planned or scheduled procedure or hospital admission?*
- Yes
- No
If "yes", please provide date, time, procedure/admission, and place:
Additional Patient Information or Comments:
Please check the box below:

Contact Us

For general questions or feedback, you can send an email to [email protected], reach out to the PATCH Program Coordinator [email protected]; or call 402-955-5400 and ask to speak Dr. Patricia Sullivan in Behavioral Health.

For questions regarding a specific PATCH patient or Adaptive Care Plan contact Child Life Specialist, Rob Harding, [email protected] 402-955-3594; or Child Life Supervisor, Nikki Walker, [email protected], 402-955-5322.

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PATCH Provider Referral Form

Patient Information

Referring Physician/Practitioner Information

Referral Information

Contact Us

Give Feedback

Primary Care

Virtual Visits

The Child Health Research Institute

Research Facility Opportunities

Embrace Our Passion, Advance Your Career

Patient Information

Referring Physician/Practitioner Information

Referral Information

Contact Us

Give Feedback

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