Demographic Information

Full Name *

Birth Date *

Gender *
MaleFemaleNon-binaryPrefer not to answer

Parent/Guardian Name *

Address *

City *

State *

Zip code *

Phone *

Email *

Current School *

School Type *
Public/Charter SchoolPrivate SchoolFlorida VirtualDaycareOther

School Placement *
Regular educationEmotional/behavioral (EBD)Other special education

Service Needs

Other Current Services (Counseling, OT, PT, Speech, tutoring)

Bilingual staff required? *
NoKreoleSpanish

Dependency * (FC/PS) (Is a Dependency Case Manager involved?)
YesNo

Funding Information

Other Referral Information
MedicaidHealthy KidsPrivate PayOther

Plan Name
AHCA (Medicaid)Aetna Better Health (Medicaid)Beacon/Humana (Medicaid)Beacon/Molina (Medicaid)Beacon/Simply (Medicaid)Molina Healthcare (Medicaid)Sunshine/CMS-T19 (Medicaid)Sunshine/CW Sunshine (Medicaid)Sunshine/Sunshine State (Medicaid)Sunshine/CMS T21 (CMS)United (Medicaid)Aetna Better Health (Healthy Kids)Beacon/Simply (Healthy Kids)

Medicaid ID#

Referral Source

Referral Date

Referring Person *

Referring Agency

Referral Source Phone

Referring Email

Client Primary Diagnosis Code

Referring Physician

Referring Physician Phone

Referring Physician Fax

Choose the Office *
South FloridaCentral Florida

Files

Physician order for ABA services
Diagnostic Assessment (CDE) verifying physician di
Other Document