PRESTIGE 861 Community Health Centers Of Sarasota County Outside Agency Referral Form
User Manual: PRESTIGE 861
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Community Health Centers of Sarasota County
Florida Department of Health
Client Information (please print): Date of Referral: _____ / _____ / ______
Last Name ______________________________________ First Name __________________________ Middle Initial: ______
SS# ___ ___ ___ - ___ ___ - ___ ___ ___ ___ DOB _____/_____/_____ Sex _____ Race ____ County _____________
Parent/Guardian __________________________ Phone 1 (__ __ __) __ __ __ - __ __ __ __ Phone 2 (__ __ __) __ __ __ - __ __ __ __
Home Address ________________________________________ Apt # ________ City ____________________ Zip ____________
Referral Source Information Name/ Agency/Clinic ____________________________________________________
Email (PRINT CLEARLY!) ______________________________________________________________________________________
Phone (__ __ __) __ __ __ - __ __ __ __ Fax (__ __ __) __ __ __ - __ __ __ __ Contact Person __________________________________
FILLED OUT BY CASE MANAGER, CLIENT, OR LEGAL GUARDIAN OF CLIENT
Primary Reason(s) for Referral
[__] Anxiety
[__] Inattention/Hyper
[__] Depression
[__] Substance Abuse
[__] Sexual Acting-Out
[__] Trauma / Grief / Loss
[__] Low Self Esteem
[__] Verbal Aggression
[__] Social Skills
[__] Non-Compliance
[__] Bullying
[__] Family Issues
[__] Physical Aggression
[__] Defiance/Disrespect
Comments:
North Port Health Center
6950 Outreach Way
North Port, FL 34287
Phone: (941) 861-3846
Fax: (941) 861-3394
Children’s Health Center
1750 17th St, Building E
Sarasota, FL 34234
Phone: (941) 861-1400
Fax: (941) 373-7676
William L. Little Health
and Human Services
2200 Ringling Blvd.
Sarasota, FL 34237
Phone: (941) 861-2744
Fax: (941) 861-2705
PLEASE FAX any updates to the APPROPRIATE OFFICE (based on client’s residence)
[__] STRAIGHT-MEDICAID [__] AMERGROUP
[__] PRESTIGE [__] AETNA
[__] SUNSHINE [__] BC/BS
[__] INTEGRAL [__] STAYWELL/WELCARE
[__] MEDICARE [__] MEDICARE/MEDICAID
[__] HEALTHY KIDS
[__] SELF-PAY
[__] OTHER:
Medicaid Number (10 digits)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
