Begin with a referral conversation.

Families and professionals can use this form to share non-clinical contact and routing information. It begins an initial conversation and does not guarantee admission.

Tell us how to reach you.

This first step helps our team understand who is referring, which program may be relevant, and when to follow up. Fields marked with an asterisk are required.

Referrer name

Professional title or relationship

Organization

County or general location

Phone number

Email address

Broad current setting

Program interest

Timing or urgency

Preferred contact method

Phone Email Either is fine

Short general note

Important: Do not include medical details or protected health information in this form.

Do not include the prospective resident’s name, diagnoses, medications, equipment, records, insurance identifiers, Social Security number, or other private health information.

I confirm that this inquiry contains no medical details or protected health information, and I authorize Excellent Care to contact me about this referral inquiry.

Your non-clinical inquiry will be sent directly to our team. Do not include medical details or protected health information.

Your referral inquiry was sent.

Your non-clinical inquiry was sent to Excellent Care. Our team will follow up using your preferred contact method. If your timing is urgent, call us at (954) 399-9141.

Call Excellent Care

What happens after the first contact?

We contact the referrer.

A team member follows up using the preferred contact method to clarify the broad request and next step.

Permission comes first.

Medical records or protected information should only be shared later through an appropriate process and with proper authorization.

The team reviews fit.

If the inquiry proceeds, Excellent Care coordinates an individualized residential, clinical, funding, and capacity review. Admission is never guaranteed by submitting this form.