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Note This must be a SECURE Email. LA CSoC Referral Form Date of Referral Healthy LA Plan Name Staff Referring Phone Youth Name Aetna Better Health Email Date of Birth Medicaid Number Gender Male Anticipated Discharge Date Legal Guardian s Name Relationship to Youth o Cell Home Work Parish Consent Form Attached Referral Source Care Giver Referral Contact Reason for Referral Yes to risk question Diagnosis if known Current Behaviors Medical Issues Current Medications Primary Care Physician Name...

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