Specialized Therapeutic
Services — Referral
1 · Referral source
Referrer name
Organization / practice
Email
Phone
Date of referral
2 · Client information
Client full name
Date of birth
Preferred pronouns
Phone
Email
Parent / guardian (if under 18)
Guardian phone
Medicaid ID / funding agency / private pay
Member ID (optional)
3 · Services requested
Funding:
Services outside the Florida Medicaid covered services (or beyond Medicaid service limits) require an agency funding authorization or private pay.
Urgency:
4 · Reason for referral
A brief summary is sufficient. Relevant records may be shared separately with appropriate authorization.
5 · Consent
I confirm the client (or their legal guardian) is aware of and agrees to this referral, and that Specialized Therapeutic Services may contact them to schedule an intake.
Signature
Date