Provider Referral Form | Fort Lauderdale FL

Provider Info

Patient Info

Areas of Concern

Review & Submit

Important Privacy Notice

Note: This form is not HIPAA-compliant. Please do not include any personally identifying information (PHI) such as the child's name, date of birth, address, school name, or parent/guardian contact information.

Step 1: Referring Provider Information

Please provide your contact information so we can follow up on this referral.

Full Name (required)

Please enter your full name.

Professional Title (required)

Pediatrician Psychologist Psychiatrist Therapist School Counselor School Psychologist Teacher Other

Please select your professional title.

Organization/Practice Name (required)

Please enter your organization name.

Phone Number (required)

Please enter your phone number.

Email Address (required)

Please enter your email address.

Preferred Contact Method (required)

Phone Email Either

Please select a preferred contact method.

Step 2: Patient Information

Provide general information about the child. Do not include identifying details.

What is the child's primary language(s)? (required)

Select all that apply:

English Spanish Portuguese French Haitian Creole Chinese Vietnamese Arabic Russian Other

Please select at least one language.

Is the child verbal? (required)

Yes Limited No

Please select an option.

Does the child have significant vision or hearing impairments? (required)

Yes No

Please select an option.

Is the child currently in school? (required)

Yes No

Please select an option.

What grade is the child currently in?

What type of classroom is the child currently attending?

General education Special education Self-contained

What school-based services is the child currently receiving?

Select all that apply:

504 Plan Assistive technology supports Behavioral intervention services Counseling or school-based therapy Extended school year services Formal classroom supports/accommodations Individualized Education Program (IEP) Occupational therapy Physical therapy Social skills groups Speech/language therapy Tutoring

Step 3: Areas of Concern

Provide clinical information and select all areas of concern that apply. (required)

Does the child have any prior neurodevelopmental or psychological diagnoses?

Yes No

If yes, select all that apply:

Attention-Deficit/Hyperactivity Disorder (ADHD) Anxiety Disorder Autism Spectrum Disorder Developmental Coordination Disorder Disruptive Behavior Disorders Global Developmental Delay Intellectual Disability Language Disorder Learning Disability Mood Disorders Motor Disorders (Tourette's, Tic Disorders) Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder Trauma-Related Disorders

Service Requested (required)

Neuropsychological Assessment Consultation Other (please specify)

Please select a service.

Please provide a brief summary of the primary reason for this referral: (required)

Please provide a reason for referral.

Developmental

Delayed developmental milestones Early learning delays Other developmental concern

Cognitive

Academic skills Attention/concentration Expressive language Fine motor Gross motor Impulse control Learning/memory Planning/organization Receptive language Speed of processing Time management

Behavioral

Aggression Noncompliance Rigidity/inflexibility Self-stimulatory behaviors Sensory regulation Separation issues Tantrums

Emotional

Anxiety Depression Trauma

Social

Difficulty getting along with peers Experiences bullying or social exclusion Group participation/engagement Peer initiation/interactions Prefers to play alone Social-emotional reciprocity

Please select at least one area of concern.

Step 4: Review & Submit

Please review your information and confirm the statements below before submitting.

Urgency of Referral (required)

Routine (evaluation in 1–3 months) Moderate concern (evaluation in 2–4 weeks) Urgent (evaluation within 1–2 weeks) — please call our office after submitting

Please select the urgency level.

Consent & Compliance (required)

I confirm that I have not included any protected health information (PHI), including names, dates of birth, addresses, or any other identifying details related to the child or their family. (required) I understand that someone from your team may contact me or my organization to coordinate general next steps. (required)

Thank You for Your Referral

Our team will review the information to determine appropriateness and next steps. When indicated, we will contact the family directly and/or follow up with the referring provider to discuss the referral. We appreciate your partnership in supporting this child's care.

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