Phone:
813.754.5555
Email:
info@headsusa.com
Fax:
813.754.5552
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Specialized Therapeutic Foster Care
Behavioral Health Therapy
Referral Form
Primary Care Physician Contact
Consent for Treatment
Confidential Info Consent
School Permission Letter
Behavior Checklist
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Confidential Info Release Consent
Day Program
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Referral Form
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Confidential Info Consent
School Permission Letter
Behavior Checklist
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Referral Form
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Client Information
Client's First Name
*
Client's Last Name
*
D.O.B
Date Format: MM slash DD slash YYYY
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
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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
Handbooks
Client Handbook
Manual del Cliente
Telehealth
Telehealth Consent
Consentimiento De Telesalud
Extension
Disaster Plans
Careers
Contact us