Online Referral

ZIP CODE *

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.

If you have previously participated in our program, we are unable to offer services again at this time.

We encourage you to explore other programs in the community. Thank you.

Please do not apply as your application will not be processed.

FULL FIRST NAME: *

Email: *

INSURANCE *

PHONE NUMBER *

BIRTHDATE *

LAST NAME: *

Date and time *

DO Y0U HAVE A CURRENT MENTAL HEALTH ASSESSMENT *

YES- PLEASE UPLOAD

NO- YOU WILL BE REQUIRED TO OBTAIN ONE

SOCIAL SECURITY NUMBER *

REASON FOR REFERRAL *

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

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.

Member of South Tampa Chamber of Commerce

Welcome!

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

RE-ENROLL FORMER CLIENTS INTO THE PROGRAM.

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

RE-ENROLL FORMER CLIENTS INTO THE PROGRAM.

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