Referring to Hearts Connected
Please complete this short form to referral a child and/or family to a Hearts Connected Certified Child Life Specialist. Thank you!
Referral being completed and requested by a professional or a professional organization
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Pediatrician/ Family Practitioner/ Primary Care Provider
Pediatric Specialist (ex.-Gastroenterologist, Otolaryngologist, Palliative Care)
Child Life Specialist
School Teacher/ Counselor
Behavioral Health Specialist
Other
Referral Contact
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First Name
Last Name
Referral Email
*
example@example.com
Referral Phone Number
*
-
Area Code
Phone Number
Optional: Additional information about referring party:
Reason for Referral
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Client Appointment
*
The online appointment has been made on HeartsConnected.org website
Please contact the family to assist them in scheduling an appointment.
The parent/guardian will independently schedule their appointment online with you, but would benefit from a follow-up.
Other
Please send post-session notes, in a HIPAA compliant fashion, after receiving parental consent to:
*
Email listed above
Other
Parent/ Family/Child Information
Child's Name
*
First Name
Last Name
Age
*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: