Technology Assisted Children's Home Program Provider Referral

Health Promotion Council (HPC) of Southeastern Pennsylvania is enrolling families into a new program called the Technology-Assisted Children’s Home Program (TACHP). The goal of TACHP is to provide non-medical services to families caring for technology-assisted children with special health care needs in their home. Please review the criteria detailed on our brochure and complete this form for each child that you are referring to TACHP.

TACHP Brochure

1. Today's Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Referring Provider Information

First name *This question is required.

Last name *This question is required.

Organization *This question is required.

Street address *This question is required.

City *This question is required.

Zip Code *This question is required.

Phone number *This question is required.

Fax number

Email adress *This question is required. This question requires a valid email address.

Now we would like to know the contact information of the child you are referring. Only one form is to be submitted per child.

3. Child's Information *This question is required.

First name

Last name

Date of birth mm/dd/yyyy This question requires a valid date format of MM/DD/YYYY.

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Gender

7. Parent/Caregiver Information

First name *This question is required.

Last name *This question is required.

Street address *This question is required.

City *This question is required.

ZIP code *This question is required.

Home phone number

Cell Phone number

Email address This question requires a valid email address.

Primary language spoken at home

8. Are there any additional comments you would like to add?