Referral Form

Referral to: (Recipient agency)

The Pediatric and Adolescent Center Phone Number: (302) 684-0561
Address: 424 Mulberry St., Miltion, DE 1996

From: (Referring agency)

Referring agency: TidalHealth
Referrer’s name: Yaisa Paxtor, RN
Contact details: (302)519-1018
Client details:
Name: EP
Date of birth: 06/05/2007
Address: 304 6th St, Laurel, DE 19956
Telephone no: NA Mobile no: (302)470-3234
Parent/ Guardian

OP Father (302)245-9704
ZG Mother (302)490-2181

Presented on: 4/21/2024

For assistance with: Difficulty sleeping

Preferred language is:English

In the course of his assessment, Mr._P__ is advised to follow up with PCP, for hospital follow up.

To discuss possible medications for proper sleep, parents have been consulted and agreed.

115