Phone:
813.754.5555
Email:
info@headsusa.com
Fax:
813.754.5552
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Primary Care Physician Contact
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It is the policy of HEADS to work in partnership with other providers in the treatment of your child. Please answer the questions below and then, by your signature, you give HEADS, LLC. the authority to contact your child’s primary care physician, if you have one, or not to contact if you choose that option. At all times, HEADS will respect your wishes.
Client's Name
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Does your child have a primary care physician?
*
Yes
No
Do you want HEADS, LLC. to contact your child's PCP to let them know we are providing services to your child?
*
Yes
No
Name of Primary Care Physician:
*
Telephone Number:
*
Fax Number:
Client or Legal Guardian Signature
*
Printed Client or Legal Guardian Name
*
Date
*
Date Format: MM slash DD slash YYYY
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Home
About us
Programs
Specialized Therapeutic Foster Care
Behavioral Health Therapy
Referral Form
Primary Care Physician Contact
Consent for Treatment
Confidential Info Consent
School Permission Letter
Behavior Checklist
Psychiatric Consent
Telehealth Consent
Confidential Info Release Consent
Day Program
Psychiatric Consent
Referral Form
Primary Care Physician Contact
Consent for Treatment
Confidential Info Consent
School Permission Letter
Behavior Checklist
Off Premises Consent
Confidential Info Release Consent
Client Handbook
Español
Terapia de salud conductual
Formulario de referencia
Contacto con el médico de atención primaria
Consentimiento para el tratamiento
Consentimiento de información confidencial
Carta de permiso escolar
Lista de verificación de comportamiento
Consentimiento psiquiátrico
Consentimiento de telesalud
Consentimiento de divulgación de información confidencial
Consentimiento De Extensión
Consentimiento De Telesalud
Consentimiento para Traductor
Manual del Cliente
Telehealth
Extension
Disaster Plans
Careers
Contact us
