Referring to Hearts Connected
Please complete this short form to referral a child and/or family to a Hearts Connected Certified Child Life Specialist services. Thank you!
Referral being completed and requested by a professional or a professional organization
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Pediatrician/ Family Practitioner/ Primary Care Provider
Pediatric Specialist (ex.-Gastroenterologist, Otolaryngologist, Palliative Care)
Child Life Specialist
School Teacher/ Counselor
Behavioral Health Specialist
Other
Are you referring this individual to:
A Hearts Connected CCLS
Ursula Stahl, Hearts Connected Affiliate
Referral Contact
*
First Name
Last Name
Referral Email
*
example@example.com
Referral Phone Number
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-
Area Code
Phone Number
Optional: Additional information about referring party:
Client demographics
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I have or will email a family demographics document, via HIPAA compliant methods, to info@heartsconnected.org
I will provide contact information below
Reason for Referral
Client Appointment
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The online appointment has been made on HeartsConnected.org website
Please contact the family, up to three times, to assist them in scheduling an appointment.
The parent/guardian will independently schedule their appointment on line with you.
Please send post-session notes, in a HIPAA compliant fashion, after receiving parental consent to:
*
Email listed above
Other
Parent/ Family/Child Information
Child's Name
*
First Name
Last Name
Age
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: