Phone:
813.754.5555
Email:
info@headsusa.com
Fax:
813.754.5552
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Specialized Therapeutic Foster Care
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Confidential Info Consent
School Permission Letter
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Referral Form
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Client Information
Client's First Name
*
Client's Last Name
*
D.O.B
Race/Gender
SSN
Medicaid Number:
Phone
Grade
Client currently lives with:
Bio-Parents
Relative Placement
Non-Relative Placement
Foster care
Group Home/Facility/Other
Self
Language spoken
Name of Caregiver (if applicable)
Phone
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Is client receiving mental health services at another agency?
Yes
No
If "Yes", please explain what services & at what agency?
Provider/Facility Name:
Please upload any additional documents you would like us to review (Medicaid Card, Signed consents, I.E.P./ Report Card, Comp. Assessment, Any Court Documents & Immunization Records/ Medical Records).
Drop files here or
Agency Information
No additional information need
Referring Agency/Person
Your Name and Title
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Office Phone
Cell Phone
Email
Fax
Reason For Referral
*
Special Instructions
Medications
Email address for your copy:
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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
Psychiatric Consent
Day Program
Referral Form
Primary Care Physician Contact
Consent for Treatment
Confidential Info Consent
School Permission Letter
Psychiatric Consent
Off Premises Consent
Handbooks
Client Handbook
Manual del Cliente
Disaster Plans
Careers
Contact us