Referring to Hearts Connected
Please complete this short form to referral a child and/or family to a Hearts Connected Certified Child Life Specialist services. Thank you!
Referral being completed and requested by a professional or a professional organization
Pediatrician/ Family Practitioner/ Primary Care Provider
Pediatric Specialist (ex.-Gastroenterologist, Otolaryngologist, Palliative Care)
Child Life Specialist
School Teacher/ Counselor
Behavioral Health Specialist
Referral Phone Number
Optional: Additional information about referring party:
I have or will email a family demographics document, via HIPAA compliant methods, to email@example.com
I will provide contact information below
Reason for Referral
The online appointment has been made on HeartsConnected.org website
Please contact the family, up to three times, to assist them in scheduling an appointment.
The parent/guardian will independently schedule their appointment on line with you.
Please send post-session notes, in a HIPAA compliant fashion, after receiving parental consent to:
Email listed above
Parent/ Family/Child Information
Parent/Guardian Phone Number
Should be Empty: