Contact | Latino Kids and Family Mental Health

Contáctanos | Contact Us

¿Tiene alguna pregunta o necesita más información? Estamos aquí para ayudarle. Complete el formulario de contacto a continuación y uno de nuestros miembros del equipo se comunicará con usted lo antes posible.

Have a question or need more information? We're here to help. Complete the contact form below, and a member of our team will get back to you as soon as possible.

Nombre Completo del Paciente | Patient's Full Name *

Fecha de Nacimiento del Paciente | Patient's Date of Birth *

Edad del Paciente | Patient Age *

Nombre del Padre, Madre o Encargado Legal (si el paciente es menor de edad) | Parent or Legal Guardian's Name (if the patient is a minor)

Correo Electronico/ Email address *

Telefono/ Phone *

Identificación con foto | Photo Identification (Photo ID)

Nombre del Plan Médico | Health Insurance Plan Name *

Foto del frente de la tarjeta de seguro médico | Photo of the Front of Your Insurance Card

Foto del reverso de la tarjeta de seguro médico | Photo of the Back of Your Insurance Card

Carta u orden de referido | Referral Letter or Referral Order

¿Quién le refirió a nuestros servicios? | Who referred you to our services?

¿Hay algo más que le gustaría que supiéramos sobre usted o su situación actual? | Is there anything else you would like us to know about you or your current situation? *

Are you a provider or clinic wanting to make a referral?

We welcome referrals from pediatricians, schools, therapists, agencies, and community providers. Our team offers bilingual mental health services and psychological/neuropsychological evaluations for children, adolescents, and families.

To refer a client, please complete our referral form or contact our office directly. We will review the information and follow up with the family to begin the intake process.

Patient Name *

Patient Age *

Parent's or caregiver name

Patient Phone Number *

Email

Insurance Information *

The Client Language of Preference is: *

English
Spanish
Other

Referring Provider *

Upload Additional documentation or information

Anything Else We Should Know?

Send me a copy

Address

125 North Moon Ave Brandon Fl 33510

Contact

Phone: 813-278-7644

Fax:813-922-0031

lkfmentalhealth@gmail.com

Opening Hours

Mon - Fri: 9am - 6pm

Saturday: 9:00am - 3pm

Sunday: Closed

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