Professional and Provider Referrals
Please complete this form so that we may collaborate in assisting your patients, clients and families with educational services.
Name of Referring Professional or Provider
Name of Referring Professional or Provider's Organization
Professional or Provider Email Address
Phone Number of Referring Professional or Provider
Professional or Provider Business Address
Patient's First Name
Patient's Last Name
First Name of Parent/Legal Guardian
Last Name of Parent/Legal Guardian
Parent/legal guardian email address
Parent/Legal guardian phone number
Patient and Legal Guardian Home Address
Select one or more reasons for referral. If Other, please describe the reason for referral in the following section.
Patient has a mental health diagnosis
Patient has a medical diagnosis
Patient is admitted to an inpatient facility
Patient is admitted to PHP
Patient is admitted to IOP
Patient requires homebound services
Patient needs a new support plan at school
Concern that patients' current support plan at school is not beneficial
Other
If Other is selected in the above field, please describe the reason for referral
Upload any pertinent information that may be helpful in assisting your patient with educational services. Such documents may include medical and mental health diagnoses, current therapies or treatments, and any academic challenges you are aware of.
Select a File
Please confirm that your patient, client and/or family are aware of this referral and they agree to releasing protected health information for the purpose of collaboration in providing educational services.
Date
Signature of referring professional or provider
*
Professional or provider signature
Submit