Referral Form

In order to make a referral you may fill out the form below or download the referral form and send it to us as you wish. Download This Form


Your privacy is important to us. This form is encrypted and HIPAA compliant.


DEMOGRAPHIC INFORMATION

Name: *
Social Security #:
Date of Birth:
Parents/Caregivers Names:
Relationship to Client:
Address:
County:
City:
State:
Zip:
Phone Number: *
Phone Number 2:
Email: *
Sex:
Male Female
Race:
White Black Hispanic Asian/Pacific Haitian Bi-racial


OTHER CURRENT SERVICES

No Current Services
Mental Health Counseling
Name: Phone:
Psychiatric/Medication
Name: Phone:
Other
Name: Phone:


REFERRAL SOURCE INFORMATION

Referring Agency:
Person Completing Form:
Phone:
Phone 2:
Fax:
Email:


SERVICES REQUESTED

Behavior Analysis Counseling Play Therapy Psychiatry
Psychological Testing Parent Training Speech Therapy Nutritional Counseling
Support Group Infant Sign Language Infant Massage Tutoring
Adoption Home Study or Post Placement


FUNDING INFORMATION

Medicaid #:
Harmony
Amerigroup
United
FHP
Citrus
Magellan
AHCA
Other Insurance:
ID#: Group#:
Insurance Phone:
Auth Info:


PROBLEM DESCRIPTION

Physical Aggression Failure to Thrive Tantrums Lying
Depressed Affect Verbal Aggression Property Destruction Truancy
Victim of Abuse Anxious Affect Non-Compliance Harmony
Stealing Self-Injury/Suicidal Toileting Problems
Other
Reason For Seeking Service: