You must have JavaScript enabled to use this form. Date of Referral Name of Person Completing This Referral Relationship to Consumer Contact Information Consumer Information Name DOB Phone Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon 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 No 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
