(Para Español precione aqui) Carrousel Therapy Center New Referral Form CLIENT INFORMATION FIRST NAME * LAST NAME * Full Name * Email * PARENT/GUARDIAN NAME COUNTY * BrevardOrangeOsceolaPolkSeminoles REFERRAL DATE * DATE OF BIRTH * SEX * MaleFemale ETHNIC Hispanic or LatinoNon Hispanic or Latino RACE American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite SSN HOME PHONE * CELL PHONE * PREFERRED PHONE * HomeCell ADDRESS * CITY * STATE * ZIP CODE * LANGUAGE PREFERENCE * English Spanish SCHOOL GRADE ESE CLIENT ID Picture ID * Drop a file here or click to upload Choose File Maximum file size: 41.94MB SERVICE REQUIRED SERVICE REQUIRED (Select all that apply) * PSYCHIATRIC EVALUATION MENTAL HEALTH COUNSELOR MEDICATION MANAGEMENT TARGETED CASE MANAGEMENT PSYCHOSOCIAL REHABILITATION SERVICES PSYCHOLOGICAL TESTING REASON FOR REFERRAL REASON FOR REFERRAL (Select all that apply) * DEPRESSION STEALING VERBAL AGGRESSION INAPPROPRIATE SEXUAL BEHAVIOR NON COMPLIANCE TRAUMA ANXIETY SUBSTANCE ABUSE ADD/ADHD OTHEROTHER CURRENT OR PREVIOUS TREATMENT CURRENT TREATMENT (Please Explain) PREVIOUS TREATMENT (Please Explain) DIAGNOSIS (Please Explain) MEDICATIONS (Please Explain) COMMENTS PHYSICIAN INFORMATION PHYSICIAN’S NAME PHYSICIAN’S NPI PHYSICIAN’S PHONE PHYSICIAN’S FAX INSURANCE INFORMATION Insurance * AetnaAetna CommercialAetna HMOAmbetter Complete Value GoldAmBetter/Sunshine HealthBCBSChampvaCignaMolina CommercialOscarAetna Medicare/MedicaidUnited Health CareAetna (Florida Kid Care)CMS Title XXI (Florida Kid Care)Simply/Healthy Kids (Kid Care)Aetna (Medicaid)CMS Title XIX (Medicaid)Devoted MedicaidFlorida Community CareFreedom (DSNP Full Medicaid)Humana (DSNP Full Medicaid)Humana (Medicaid)Medicaid (Straight Medicaid)Molina HealthCare (Medicaid)Simply (Medicaid)Sunshine (Medicaid)United Health CareUnited Health Care (DSNP Medicaid)United Health Care (Medicaid)United Health Care (Dual Complete)Cigna (Medicare)Devoted/Magellan (Medicare)Freedom (Medicare)Humana (Medicare)Humana Gold Plus (Medicare Advantage)Medicare BSimply (Medicare)United Health Care (Medicare)WellCare (Medicare)Tricare (Military)Cigna Allegiance (Disney/AdventHealth)Others Secondary Insurance Aetna MedicaidUnited Health CareAetna (Florida Kid Care)CMS Title XXI (Florida Kid Care)Simply/Healthy Kids (Kid Care)Aetna (Medicaid)CMS Title XIX (Medicaid)Devoted MedicaidFlorida Community CareFreedom (DSNP Full Medicaid)Humana (DSNP Full Medicaid)Humana (Medicaid)Medicaid (Straight Medicaid)Molina HealthCare (Medicaid)Simply (Medicaid)Sunshine (Medicaid)United Health Care (DSNP Medicaid)United Health Care (Medicaid)Humana (Medicaid)Simply (Medicaid)United Health Care (Medicaid)Others INSURANCE ID * INSURANCE OTHER ID Picture of Insurance Card * Drop a file here or click to upload Choose File Maximum file size: 41.94MB REFERRAL SOURCE REFERRAL FULL NAME * REFERRAL AGENCY REFERRAL EMAIL * REFERRAL PHONE REFERRAL FAX REFERRAL TAKEN BY REFERRAL REQUESTED THERAPIST: DISCLAIMER Confirmation * I confirm that all information in this form is correct, especially name, date of birth, and insurance details. Incorrect information may delay the scheduling of your appointment with our professionals. Submit If you are human, leave this field blank. WordPress Google Maps Plugin Share Post Share
