Get Nassau/suffolk Counties Universal Referral Form - Single ... - Bellmore-merrick Schoolwires

Filling out the NASSAU/SUFFOLK COUNTIES UNIVERSAL REFERRAL FORM is an essential step in accessing children’s intensive mental health programs. This guide provides a structured approach to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the referral form

1. Press the ‘Get Form’ button to access the referral form and open it in your designated document editor.
2. Enter the date of referral in the designated field, along with the child's name and their date of birth. Indicate the child's gender and provide the child's residential address, social security number, and phone number.
3. Identify the legal guardian. Record their name and relationship to the child. If the legal guardian has a different address or phone number, include that information in the provided fields.
4. Fill in the emergency contact details including the contact's name and phone number.
5. Specify the child’s insurance provider and include the insurance policy number or Medicaid CIN.
6. Check any applicable benefits the child is currently receiving, such as SSI, SSD, or Child Health Plus.
7. Provide the referral source information by filling in the name and contact number of the person or agency making the referral.
8. Clearly state the reason for this referral, outlining any pertinent information that justifies the referral.
9. Select the appropriate service category in which the child is being referred. Check all that apply.
10. Sign and date the application, using both the parent/guardian's signature and their printed name. If applicable, include the child’s signature and the name of any witness signing the form.
11. Complete the second page with details about the child's history, current living arrangements, education, diagnosis, medication, and any past services received.
12. Finish completing all sections regarding strengths, needs, and other relevant behaviors.
13. Upon completion, save any changes made to the document. You can then download or print the completed form for submission.

Ensure you complete the NASSAU/SUFFOLK COUNTIES UNIVERSAL REFERRAL FORM accurately online to facilitate timely access to mental health services.