FRDC Treatment Request Form

* 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

Please complete all fields below and our office manager will respond as quickly as possible to discuss treatment options with you

"*" indicates required fields

MM slash DD slash YYYY
MM slash DD slash YYYY
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?
*Reasons may include suspected undiagnosed ADHD or other executive skill diagnosis, clarification of diagnosis, request for diagnosis verification by school, exploring treatment needs, skills training and support
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 agree to self-pay if my insurance is not accepted by the assigned clinician*