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Staff use. All information is secure and used only to process this outgoing referral. The generated PDF may be given to the client and/or uploaded into the client's file.
Referring Out for Services
Complete this form to refer an existing client out to another provider.
Referring Staff Member
Staff Name
*
Required.
Staff Title / Role
Staff Email
*
Enter a valid email.
Client Information
Client First Name
*
Required.
Client Last Name
*
Required.
Date of Birth
*
Required.
Client Phone
Street Address
City
State
ZIP
Insurance Company
Member ID / Medicaid ID
Referral Details
Type of Service Referred For
*
— Select —
Medical / Primary Care
Dental
Substance Use / SUD Treatment
Psychiatric / Medication Management
Mental Health Counseling / Therapy
Vision
Housing Assistance
Vocational / Employment
Legal Aid
Food / Basic Needs
Other (specify in notes)
Required.
Referred To (Provider / Agency)
*
Required.
Provider Phone
Provider Address
Urgency
Routine
Soon (within 1–2 weeks)
Urgent
Reason for Referral / Clinical Notes
*
Required.
Generate & Send Referral
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