Article 16 Clinic Treatment Program Referral for Services

Date of Referral

Name of Person Completing This Referral

Relationship to Consumer

Contact Information

Consumer Information

Name

DOB

Phone

Address

City/Town

State/Province

ZIP/Postal Code

Please Describe Current Living Environment (Group Home/Family etc.)

Parent/Guardian/Treatment Team Contact Information

Name of Parent/Guardian

Telephone Number

Has this referral been discussed with the above named individual?

Yes

Residential Agency: (if applicable)

Day Program Provider

Service Coordinator Name

Service Coordinator Agency

Service Coordinator Phone

Health Insurance - Please send in copies of cards

Medicaid #

Medicare #

Other (specify)

Service Being Requested

Psychological Counseling Services

Speech and Language Services

Occupational Therapy Services

Psychological Testing Services

Reason for Referral

(Please provide a brief description of why you are referring this person for services)

Previous Providers (if known)

Please describe strengths specific to this individual

Current Diagnosis

Signature

Person Completing this Form

Sign above

Date

For All Referrals - Please remit current copies of the following:

Insurance Cards – Medicaid Benefit Card
Most recent Psychological evaluation and Social evaluation (MSC)
Current Life Plan (Care Coordinator)

**** Addendum to Life Plan listing new service required on approval before start of services.

Helen H. Heller Health Center hours of operation:
Monday – Friday 8:00 AM to 4:00 PM

Article 16 Clinic Treatment Program Referral for Services

Consumer Information

Parent/Guardian/Treatment Team Contact Information

Signature

For All Referrals - Please remit current copies of the following:

Note: For All Referrals - please remit current copies of the following to nzelesnikar@holychildhood.org: