Online Referral

DUE TO OUR CURRENT FUNDING GUIDELINES, THE AGENCY IS NOT ABLE TO ACCEPT OR

RE-ENROLL FORMER CLIENTS INTO THE PROGRAM.

Please complete the online referral form below. An intake specialist will contact you to discuss program services and enrollment. If determined eligible, a therapist will meet with you to complete a mental health assessment.
A case manager will then be assigned to you and your family to begin services.

LAST NAME: *

REASON FOR REFERRAL *

ADDRESS: *

THIS FORM MUST BE COMPLETED IN FULL TO BE ACCEPTED. AN INTAKE SPECIALIST WILL CALL YOU WITHIN 14 BUSINESS DAYS.
Requirements for Targeted Case Management services:
*Must be receiving Sunshine health, CMS, Straight Medicaid.
*Continue to meet eligibility criteria for both Medicaid status and disability
*Continue to have a need for service referral, coordination, and monitoring for more than one service
*Participate in the development of an individual Comprehensive Plan and/or services
*Clients do not need a prior mental health diagnosis to receive services. If a mental health diagnosis is not available, our well trained and accredited staff of targeted case managers will assure the client is assessed by a licensed mental health professional in order to provide the client with an accurate mental health assessment and diagnosis.

Email: *

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INSURANCE *

PHONE NUMBER *

BIRTHDATE *

SOCIAL SECURITY NUMBER *

ZIP CODE *

FULL FIRST NAME: *

DO Y0U HAVE A CURRENT MENTAL HEALTH ASSESSMENT *

YES- PLEASE UPLOAD

NO- YOU WILL BE REQUIRED TO OBTAIN ONE

Grant funding made possible through the Children's Board of Hillsborough County and other community partners!

Thank you for your continued support!

412 E Madison Street Ste #1102 Tampa FL 33602
Office : 813.258.8887 Fax: 813.925.4351
info@sincerainc.onmicrosoft.com
Registered 501 (c)(3) Non profit organization

Sincera, Inc. is also a FLORIDA CERTIFICATION BOARD approved provider for TCM (Targeted Case Management) training

for the State of Florida.

Due to the increase of families in need, we are unable to assist if you have been enrolled with us in the past.

We apologize for any inconvenience.

Date and time *

Welcome!

Sincera, Inc. is a proud member of the Tampa/Hillsborough County Continuum of Care

Member of South Tampa Chamber of Commerce

​​​​​DUE TO OUR CURRENT FUNDING GUIDELINES, THE AGENCY IS NOT ABLE TO ACCEPT OR

RE-ENROLL FORMER CLIENTS INTO THE PROGRAM.

DUE TO OUR CURRENT FUNDING GUIDELINES, THE AGENCY IS NOT ABLE TO ACCEPT OR