Referral Form

Referring Agent

Caseworker

Phone Number

Fax Number

County Office

E-mail

Referral Source

Referral Information

DFCS Services

Wrap-Around Services Home Stead Parent Aide Early Intervention

Medicaid Services

Group Counseling Intensive Family Intervention
Community Support Services Individual/Family Therapy

Reason for Referral

Family Placement Information

Name of Care Giver

Telephone

Caregiver Address

Apartment

City

Zip

Consumer Information

Name

School/Grade

Medicaid Number

Date of Birth

SSN #

Medical Plan

Has Consumer been diagnosed or has a suspected Mental Health or Substance Abuse Disorders? (Please attach Psychological Assessment)

Yes No

Check All That Apply

ADHD Conduct Disorder Oppositional Disorder
Learning Disability Mental Retardation Bipolar/Manic Disorders
Depression

If Other Please Provide Details Here

All DFCS referrals require a Service Authorization prior to the start of services..

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