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THYROID DIAGNOSTIC ASSESSMENT CLINIC REFERRAL FORM TEL: (416) 4696031 FAX: (416) 4696458 Routine UrgentPatient ID LabelGiven Name:Patient Last Name: M Date of Birth: Address:Telephone Number Primary

How to fill out dhhs-children-s-assessment-clinic-referral-form

How to fill out dhhs-children-s-assessment-clinic-referral-form

1. Obtain a copy of the DHHS Children's Assessment Clinic Referral Form from the Department of Health and Human Services (DHHS) or their website.
2. Fill in the child's personal information such as name, date of birth, address, and contact information.
3. Provide details about the reason for the referral and any relevant background information about the child's medical history or current concerns.
4. Include information about the child's primary care provider and any other professionals involved in their care.
5. Sign and date the form to verify the information provided.
6. Submit the completed form to the DHHS Children's Assessment Clinic as instructed.

Who needs dhhs-children-s-assessment-clinic-referral-form?

1. Parents or guardians of children who require assessment for behavioral, developmental, or psychological concerns.
2. Healthcare providers or educators who have identified a child in need of specialized assessment and support services.

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What is dhhs-children-s-assessment-clinic-referral-form?

The DHHS Children's Assessment Clinic Referral Form is a document used to refer children for assessment services provided by the Department of Health and Human Services (DHHS) for evaluation of developmental, behavioral, or psychological concerns.

Who is required to file dhhs-children-s-assessment-clinic-referral-form?

Parents, guardians, and healthcare professionals are typically required to file the DHHS Children's Assessment Clinic Referral Form when a child needs assessment for developmental or behavioral issues.

How to fill out dhhs-children-s-assessment-clinic-referral-form?

To fill out the DHHS Children's Assessment Clinic Referral Form, one should include the child's personal details, describe the concerns that necessitate the referral, provide relevant medical history, and include any supporting documentation from other professionals if available.

What is the purpose of dhhs-children-s-assessment-clinic-referral-form?

The purpose of the DHHS Children's Assessment Clinic Referral Form is to initiate the process of evaluating children for developmental and behavioral issues to ensure they receive the necessary assessments and interventions.

What information must be reported on dhhs-children-s-assessment-clinic-referral-form?

Essential information to report includes the child's full name, date of birth, address, description of the presenting issues, developmental milestones, medical history, and contact information for the person making the referral.