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TSI Health Online Referral Form

Please complete the form in it's entirety. Any documentation that is not uploaded with this referral, may result in a longer wait time for services. Contact referrals@tsihealthjax.com with any questions you may have.

Gender
Diagnosis Information
Please select one or more.
Address
  • {name}
Case Manager Name and Contact
Please complete this section if you are completing this referral on behalf of caregiver/parent.
  • {name}
Grade Level
Services Requested
Please select at least one service.
Behaviors of Concern
Doctor's Letter
(Medical Prescription Letter) This is REQUIRED by Medicaid for Applied Behavior Analysis services. Any ABA referral without a Doctors letter will not be able to be processed.
Attach file
Drop files here
Other Required Documents
School IEP MD Diagnostic Medical Reports Recent Psychatric Evaluations These documents are REQUIRED by Medicaid for Applied Behavior Analysis services. Any ABA referral without these documents will not be able to be processed.
Attach file
Drop files here
Additional Supporting Documents
CBHA Court Documentation DJJ summaries Inpatient Hospitalization Summaries School Referrals/Suspensions
Attach file
Drop files here
Insurance Type
Please select from the options below.
If you do not know the Member ID, please enter "NA"
Does the client receive any additional services?
Please list all additional services
Additional Information
Any additional information we should know about client?
  • {name}

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