Parents/Caregivers: To make a self-referral for peer parent family support services, click here.
Your referral to a Direct Support Provider (DSP) must include:
1. DSP Referral Form
2. Current Assessment - Part A-C or annual update (Part E)
- Signed by a BHP within 72 hours of the evaluation OR
- Immediately signed by a BHP if the assessment is conducted by a BHPP
- The Assessment must be dated within 1 year of the prior assessment or a psychiatric evaluation signed by a Doctor (M.D., D.O.)
3. Current Service Plan
Refer to FIC for Family Support and Education (S5110, H0038, H0025) 1-15 hrs a month. Case Management (T1016) 1-5 hrs a month, Transportation (A0120, S0215) 1-5 hrs a month.
Refer to FIC for Youth Mentor Services (H2014) 1-15 a month, Case Management (T1016) 1-5 hrs a month, Transportation (A0120, S0215) 1-5 hrs a month.
Refer to FIC for Respite services (S5150) 1-30 hrs a month, Case Management (T1016) 1-5 hrs a month, Transportation (A0120, S0215) 1-5 hrs a month.
- Service plan must be dated within 1 year, signed by a BHP and a parent or guardian. Each signature must have a corresponding date directly next to it. A sign-in sheet with one date cannot be accepted.
Note: If an incomplete referral is received, we will attempt to reach the case manager for missing documentation. If we are unable to obtain required documentation the referral may be delayed or declined.
Please send the referral to:
FIC Medical Records, 602-393-1165 FAX or via secured e-mail to firstname.lastname@example.org.
If you have questions, please contact our Parent Assistance Center (PAC) by phone (602) 288-0155 or email email@example.com.