Referral form: Please fill out the form as accurately and completely as possible. If you need PDF copy of the form, Click here. Child Info: First name*: Last name*: Gender: MALE FEMALE Date of birth: Primary Language: ENGLISH SPANISH OTHER Therapy suggested: Speech Physical Occupational Child's Physician's Name: Child's Physician's Phone: Child's Physician's Fax: Source: Insurance Info: Medicaid Provider: TRADITIONAL MEDICAID PARKLAND COMMUNITY HEALTH PLAN COOK CHILDREN HEALTH PLAN MOLINA HEALTHCARE SUPERIOR HEALTH PLAN SSI OTHER Provider (if selected other): Medicaid #: Parent/Guardian Info: Full name: Phone*: Address Line: City: Zip: Select this if treatment address is same as home address. Treatment Address Line: Treatment City: Treatment Zip: Send Clear