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Horizons Clinic Application

Applicant Information
Insurance Information
Please include copies of all insurance cards (front and back) at bottom of form.
Third Party Insurance Information (If Applicable)
Contact Information
Care Manager Contact
Central Plan Coordinator Contact (If Applicable)
Residential Contact
Legal Guardian Contact
* Guardian must be notified and must give consent for the service being requested.
Medical Information
(To avoid duplication of service)
Services Requested
* Prescription for Assessment from Primary Care Physician (PT/OT only)
Please Attach Documents

Documentation Needed For Social Work Referral:

  1. Prescription from Medical Provider requesting a Social Work Evaluation
  2. Most current Psychological Testing
  3. Most current IEP/Life Plan
  4. Copies of Insurance Cards

Documentation Needed For OT/PT/SLP Referral:

  1. Prescription from Medical Provider requesting a Discipline Specific Evaluation
  2. Most current Physical Exam
  3. Most current Psychological Testing
  4. Most current IEP/Life Plan
  5. Copies of Insurance Cards

Documentation Needed For IQ Testing and/or Adaptive Testing:

  1. Most current Psychological Testing
  2. Most current IEP/Life Plan
  3. Copies of Insurance Cards
  4. Letter from Eligibility Clinic (if there has been correspondence)
  5. Medical Documentation (if pertinent to OPWDD eligibility requirements)

Documentation Needed for Capacity Assessments (Guardianship, Medical Procedure, etc.):

  1. Most current Psychological Testing
  2. Most current IEP/Life Plan
  3. Copies of Insurance Cards