Get Referral Form Please Fax To - Health Connect America

Completing the referral form for Health Connect America is a vital step to ensuring the appropriate services are provided. This guide will outline the steps needed to accurately fill out the form, enabling users to navigate the process with confidence and clarity.

Follow the steps to successfully complete the referral form.

1. Click 'Get Form' button to obtain the form and open it for editing.
2. Fill in the referring agency contact information. If you are the parent or guardian making the referral, ensure you complete the required fields, including the date, your name or agency, who referred you, your relation to the client, phone number, fax number, email address, and the school the client attends.
3. Indicate whether you have informed the family about the referral for in-home services. Mark 'Yes' or 'No'.
4. Provide details about the client including their name, date of birth, social security number, gender, race, and legal status. Ensure accuracy in this section for proper processing.
5. Complete the parent or guardian information fields, including their name, relationship to the client, and the client’s address with city and zip code.
6. List contact information for the client, including home, work, and cell phone numbers, as well as an email address.
7. Answer questions regarding the behaviors exhibited by the client, including any academic or behavioral issues they may be facing. Be as descriptive as possible.
8. Address whether the client has experienced recent trauma that may contribute to their behaviors. Provide details as necessary.
9. Note any services that have been tried in the past to address the client's needs.
10. Add any other relevant information about this referral that may assist in the evaluation process.
11. After confirming all information is filled out correctly, save the changes. You can then choose to download, print, or share the completed form as needed.

Complete your referral form online today for timely assistance and support.