Service Request Form

For Children- Please List School Child Attends

Is client out of home placement?

YesNo

If yes,

Foster CareRelative Placement

DCF caseworkers' name?

DCF caseworker's phone number

Is the client currently receiving services at another agency?

YesNo

If yes, please explain where and what services:

Legal Guardian or Power of Attorney: First and Last Name

Relationship

Phone Number

Please enter a valid phone number.

Method of Payment

Policy Number if Known

Household Income (This will not affect qualifications for services)*

Reason for Referral

Other: Explain

Primary Care Physician:

If Adult, Please provide an Emergency Contact

First NameLast Name

Referral Source*

Referral Contact Name

First NameLast Name

Referral Email

example@example.com

Has the "client" or "client’s" legal guardian been notified of this referral to Suncoast Mental Health Center? (For all outside referral sources (i.e. schools, community health centers, etc.), the client or client’s legal guardian must be notified by your agency that this referral is being made. If this does not occur first, Suncoast Mental Health is unable to accept this referral)*

Preferred Time To Contact*

Are you a previous SMHC Client*

YesNo

1. Has client ever had a head injury that required hospitalization or medical attention for 3+ days? *

2. Does the client have a primary diagnosis of autism or another pervasive disorder? *

3. Does client have a diagnosis that prevents them from participating in cognitive talk therapy? *

4. Is the client’s primary diagnosis substance abuse? *

(If “yes” to questions 1 – 4, the individual may be referred to another agency and will not be scheduled for an intake appointment)

5. Does the client or guardian have a hearing problem? *

If yes, does the individual need an interpreter?

6. Is an interpreter needed for the client or guardian who speaks Spanish? *

Indicate if another language:

Consent to Contact. By submitting this form, you are consenting Suncoast Mental Health Center to contact you via telephone (including cell phones), text messages, facsimile, email or other internet facilities, with respect to services, billing, agency updates, community resources, and other offerings. Calls may be live or pre-recorded and, calls or texts may be made via an automated dialing system. Voice and data rates may apply. Note that an individual has the right under the Privacy Rule to request and have a Suncoast Mental Health Center provider communicate with him or her by alternative means or at alternative locations, if reasonable. See 45 C.F.R. § 164.522(b).

Signature*

Service Request Form

Important