Referral Form

Email your completed referral form to referrals@activechc.org

Fax to 954-333-8621

You may also submit your information using the electronic form below which will be automatically sent to us.

Services:

Individual/Family Counseling

Substance Abuse

SEED (After School Program)

PSR Adults

Referral Source:

Name of Referring Agency:

Referral Source Name:

First Name

Last Name

Referral Source Email Address:

Referral Source Phone Number:

(###)

###

####

Client's Name:

First Name

Last Name

Client's Date of Birth:

YYYY

Siblings?

Siblings:

Client's Parent/Guardian:

First Name

Last Name

Client's School:

Client's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client/Guardian's Phone Number:

(###)

###

####

Client/Guardian's Email Address:

Insurance/Funding

Medicaid:

Insurance ID#:

Self Pay/Sliding Scale:

Presenting Problem:

Telehealth: