Larimer County HCP Referral Form

Larimer County HCP Referral Form

At HCP, we’re here to support families of children and youth with special health care needs. If you're a parent, caregiver, or healthcare provider working with a family who could benefit from our services, we invite you to complete this form — we’re ready to help.
Child/Youth's Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Child's Health Insurance (if known)
Has child received HCP services before?
Parent/s Names
Parent/s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/s Phone Number
Please enter a valid phone number.
Parent/s Email Address
example@example.com
Family's preferred method of contact:

PhoneEmail
Language Preference
Primary Care Provider (Medical Home)
Specialists
Diagnosis or Medical Needs
Reason for contacting HCP
Healthcare Providers

If this is a referral, please complete the information below:
Referral Source (Name and Agency)
Referral Source Phone Number
Please enter a valid phone number.
Has parent or legal guardian given verbal or written consent for HCP to contact them?

YesNo
Should be Empty:

Healthcare Providers