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Groups of adult program participants

Article 16 Clinic Treatment Program Referral for Services


Consumer Information


Parent/Guardian/Treatment Team Contact Information

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

Signature

Sign above

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