Get Referral Form - Chris Kids - Chriskids

Filling out the Referral Form for CHRIS Kids is an important step in accessing supportive services. This guide will provide detailed instructions to help you complete the form accurately and confidently.

Follow the steps to fill out the Referral Form effectively.

1. Click ‘Get Form’ button to obtain the Referral Form - CHRIS Kids - Chriskids and open it for editing.
2. Fill in the 'Date of Referral' field with the current date when you are submitting the form.
3. Record the 'Time of Referral' by indicating the time you are making the referral.
4. Provide the name of the 'PCP' (Primary Care Provider) and their contact number in the respective fields.
5. Under 'Referral Source', add the 'Contact Name' and clarify your relationship to the consumer.
6. Specify the organization associated with the referral, such as DFACS, School Name, or Physician's Office, along with a contact telephone number.
7. Input your email address, alongside any additional phone numbers ('home', 'work', 'cell') if relevant.
8. In the 'Consumer’s Name' field, enter the full name of the individual being referred and their date of birth (DOB).
9. Indicate the gender and ethnicity of the consumer as it pertains to the referral.
10. Complete the 'Parent or Guardian’s Name' field along with their address and contact telephone number.
11. Select the appropriate insurance information by circling the relevant insurance provider and include the Insurance ID and Group number.
12. Describe the 'Presenting Problem' clearly, providing necessary details for the assessment.
13. Outline any 'History of Problems/Involvement with other Agencies' to provide context for the referral.
14. List any 'Current Medical Problems/Medications' that the consumer is facing.
15. For internal use only, the front desk receptionist will complete the appointment details once the form is submitted.
16. Finally, save your changes, download the form, or print it to share via fax or email to the designated contacts.

Complete the Referral Form online today to connect with valuable resources.