DPC REFERRAL FORM FOR BEHAVIORAL AND THERAPY SERVICES, ADULT FORENSIC REFERRAL, AND CHILD FORENSIC REFERRAL

Make sure that you choose the correct form type.  Please have all information available prior to completing the form. This form will NOT process unless all required information is provided. All Medicaid numbers have at least 10 digits. Please connect clients to us in the FACTS system using Provider ID# 30250283.