ICU Recovery Clinic Patient Self-Referral Form

If you are interested in making a self referral to the ICU Recovery Clinic program, please complete the required fields below. A member of our team will contact you within 5 business days.

You must exhibit the factors listed below for a self referral:

  • Admission to the ICU within the last 6 months and have ongoing physical, emotional, and/or cognitive symptoms.

PLUS any of the following diagnoses during their admission:

  • Mechanical ventilation for longer than 24 hours 
  • High flow nasal cannula requirement
  • Acute respiratory distress syndrome
  • New Tracheostomy
  • Shock requiring vasopressor support for greater than 72 hours
  • Myopathy of critical illness
  • Delirium
  • Mechanical circulatory support or VV-ECMO for respiratory failure
Dates of ICU Stay
more items
Facility Address
You can also attach a medication list to the referral.
Company, plan, group

Attach a copy of insurance card and medication list

Maximum 3 files.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.