CCFA/Wrap/PUP Services Referral
Referral for Therapeutic Services
Consumer Bill of Rights
Notice of Privacy Practices
Code of Ethics
Stakeholders' Satisfaction Survey
Medicaid Referral Date (xx/xx/xxxx)
Client Name (if a minor, include parent/guardian information below)
Date of Birth:
If client is a minor: Parent/Guardian Name (please identify relationship):
Address (street, city, zip):
Medicaid # and/or Social Security # (referral cannot be processed without this information):
Referral Source and Contact Person (name, phone number, email address):
Has a Psychological Evaluation been completed in the past 12 months? If so, a copy should be faxed to 1-888-334-4283
Yes-Psy Eval HAS been completed
No-Psy Eval has NOT been completed
Is DFCS involved? If so, please provide the case manager name and contact information in the box below
No DFCS involvement
Case Manager Name and Contact Information:
If a minor, is child in foster care? If so, a copy of the most recent court order and CCFA must be faxed to 1-888-334-4283
Yes-In foster care
No-Not in foster care
This client is an adult
Is the client recieving any therapy, counseling, or psychological services?
Yes - Therapy or Counseling is currently being provided
No - Therapy or Counseling is NOT currently being provided
Therapist, Counselor, Psychologist, and/or Mental Health Contact (name and phone)
Is the person currently prescribed mental health medications?
Yes - currently taken medications
No - NOT currently taking medications
Has taken mental health medications in the past
Prescribing Psychiatrist or Physician Contact (name and phone)
Is Court involved?
No Court Involvement
Has the person/family been notified of this referral?
Yes-client/family HAS been notified
No-client/family has NOT been notified
Services Requested (please select all the services being requested for this client): Please note, to ensure continuity of care, our psychiatric services must be accompanied by therapeutic services provided within our agency.
Community Service Individual (CSI)
Intensive Family Intervention (IFI)
Provide a brief background, and an explanation of why these services have been requested:
Please notify us immediately if there are any changes to the information within this referral, including any changes to the referral source contact info.