FIPP Referral Form
To refer a child or family (or your child/family) for FIPP services, please complete the following form. Only items marked with an asterisk "*" are required. If you do not wish to enter additional information, please navigate to the last page to submit the referral and any supporting medical records or documents you would like to send. Once the referral is made, our enrollment coordinator will contact the family within 48 hours. Thank you!
REFERRAL SOURCE INFORMATION
Referral Date
*
/
Month
/
Day
Year
Name & Title
*
Agency or Practice
*
Email
*
example@example.com
Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone
*
Format: (000) 000-0000.
Does family know about referral?
Yes
No
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Child Information - Only 1 Child per Form Please
*Required Information
Name
*
Child's First Name
Child's Last Name
Middle Name
DOB
*
Gender
*
Male
Female
Gestational Age at Birth
Weeks
Weeks
Days
Days
Hearing Screen
Passed
Referred
Birth Weight
pounds
lbs
ounces
oz
Family's Preferred Language
Please Select
English
French
German
Spanish
American Sign Language
Other
Current Feeding
Please Select
Breastfeeding
Formula
Baby Food
Table Food
Tube Feeding
Other
Established condition(s)
Diagnosis Code(s)
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Reasons for Referral
*Required Information
REASONS FOR REFERRAL (please check all that apply)
*
Autism Diagnostic Evaluation (FAST)
Autism Assessment and Intervention (FAST)
Breastfeeding Support
Child Behavior
Developmental Concern
Developmental Evaluation
Family Support
Feeding Support
Nursing Support
Nutrition Education
Occupational Therapy
Parenting Education
Physical Therapy
Plagiocephaly/Torticolli Support
Speech-Language Therapy
Support in Child Care/School
Other
NOTES Please provide as much information as possible as this will help FIPP staff in serving this family
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Contact & Other Information
* Required Information
Primary Contact Name
*
First Name
Last Name
Relationship to Child
*
Mother
Father
Other
Address
*
Street Name & Number
City
Zip
State / Province
County
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (Important - needed for enrollment paperwork)
example@example.com
Best time and way to contact the family?
ie: Mom after 5pm or Grandfather before 9am
OTHER AGENCIES SERVING THE FAMILY
CDSA
CC4C
DSS
Head Start
Early Head Start
Public School
WIC
Primary Physician
Primary Practice
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Insurance Information
Not required, but helpful
Insurance Information - FIPP accepts payment in the form of Medicaid and Group/Private insurance. For families who do not have insurance, a sliding fee scale is available based on the family's income and number of family members in the home. *** No child or family is refused services based on the inability to pay.
No Insurance (Self Pay)
Medicaid Direct
Medicaid Standard Plan
Medicaid Tailored Plan
Group/Private Insurance
Infant Toddler Program
Medicaid ID Number
Medicaid Insurance Name
Please Select
Medicaid Direct
Medicaid ITP
AmeriHealth Caritas
Carolina Complete
Healthy Blue
United Healthcare Medicaid
Wellcare
Group Insurance Name
Individual ID Number
Group Number
Policy Holder Name
Policy Holder Date of Birth
Policy Holder Gender
Male
Female
Relationship to Patient
Self
Spouse
Child
Other
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File Uploads
Upload Medical Files, Releases, Insurance Card, etc.
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