Mental Health Referral Form. If you feel that you would like to collaborate your session with another provider, simply fill out the following form.Client Referral Form. Thank you for choosing to refer your patient to Brockton Home Health Care Agency. If you know someone who could benefit from our assistance, please fill out the form below and we'll send them information on how we might be able to help them! Authorization is required for members in the following plans: HMO; POS; Medicare HMO Blue. Please fill out the form below if you know someone who could benefit from our aid. We will send them information on how we might be able to help! If another client must be identified in the record do not identify that individual as a behavioral health client unless necessary. SYNOPSIS: The Physical Therapy Practice Act defines the scope of practice of physical therapists licensed in. Alabama.