* Important: Federal regulations prohibit mental health and medical providers from taking any payment from individuals covered by Medicaid/Husky. Please let us know if you are covered by Husky/Medicaid prior to your first appointment so that we can avoid any billing conflicts.

FRDC Treatment Referral Form

Due to limited schedules, FRDC therapists are only accepting clients who can manage daytime appointments between 9AM and 2PM. Children may need to come out of school to meet with their therapist. Please only proceed with appointment request if this works for you or your child.

"*" indicates required fields

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Is the client transitioning from a higher level of care (ie. inpatient or partial hospital/intensive outpatient program)?
Parent/Guardian Relationship Status:
If separated or divorced, please identify degree of current conflict with other parent:
Is the other parent in agreement with this request for the child's therapy? (unless a custody agreement communicates otherwise, our agency requires the consent of both parents for therapy to begin)
Does the referred client struggle with any aggression toward him/herself or others?
Type(s) of Therapy/Treatment Requested*
Would you like to receive periodic updates about FRDC groups, resources, etc? (all emails are sent confidentially)
Payment Source*
I am submitting this form with an understanding that FRDC Clinicians can only offer daytime therapy appointments (often during school hours)*
I agree to self-pay if my insurance is not accepted by the assigned clinician*