Referrals - Multilingual Psychotherapy Centers

1

Office Location

West Palm Beach
1639 Forum Place, Suite #7
West Palm Beach, FL 33401
(561) 712-8821

Belle Glade
233 W Ave A, Suite C
Belle Glade, FL 33430
(561) 253-3679

Hypoluxo
1111 Hypoluxo Road, Suite 106
Lantana, FL 33462
(561) 712-8960

2

Referral Source Information

Date of Referral *

Referral Source *

Referred By (Name)

Was client referred by school?

Phone

Fax

E-Mail

How did you hear about us?

3

Client Information

Full Name *

Date of Birth *

Gender

Primary Language

Race

Ethnicity

Marital Status

Living Arrangements

Has a Living Will?

Social Security #

Phone *

Alternate Phone

Emergency Contact Name

E-Mail

Address

City

State

Zip Code

School Name

School Phone

4

Parent / Guardian Information

Guardian 1

Guardian’s Full Name

Relationship

Primary Language

Legal Guardianship Docs?

Phone

Alternate Phone

E-Mail

Same address as client

Address

City

State

Zip

5

Services Requested

Please attach all assessments and background information available. This is important for a fast opening of your case.

6

Reason for Referral

Please describe in detail *

7

Client Financial Information

Funding Source *

Medicaid Number

Eligibility Checked By

8

Required Documentation

For expedited processing of your referral, please provide the documentation listed below by emailing copies directly to: Admissions@mpcipbc.com

For Minors:

Parent or legal guardian’s photo ID
Child’s birth certificate / Insurance card (if applicable)
Any legal custody, guardianship, or court documentation needed to authorize consent for services and/or psychotropic medications

For Adults:

Client’s photo ID
Insurance card (if applicable)
Guardianship or custody documents, if the client is unable to provide consent independently

Important: A parent or legal guardian must be present at the intake appointment to provide authorization and consent for services.

Confidentiality Notice: The information submitted through this form may include protected health information (PHI) and will be transmitted securely. Multilingual Psychotherapy Centers Inc. will use this information solely for the purpose of reviewing and coordinating care related to this referral. Submission of this form does not establish a provider-patient relationship. If you are experiencing a medical or mental health emergency, please call 911 or go to the nearest emergency room. For more information on how we protect your information, please refer to our Notice of Privacy Practices.