Get (wise) Referral Form - Family Alliance

Filling out the (WISe) Referral Form - Family Alliance is an important step in accessing necessary support services. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to complete the (WISe) Referral Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Enter the referral date, the name of the person making the referral, and their affiliation in the specified fields. Ensure accuracy as this information is critical for processing.
3. Complete the 'Time' and 'Referent Phone' sections. Provide a contact number to facilitate follow-up communication.
4. Indicate if the youth/child meets the eligibility criteria: actively enrolled in Medicaid, residing in Thurston or Mason County, and under the age of 21. If any criterion is unmet, note that they are not eligible for WISe services.
5. In the 'Provider 1' section, enter relevant details and if applicable, answer the question regarding Managed Care Information accurately.
6. Fill out the address, child/youth name, date of birth, gender, and phone number. Please be thorough to avoid delays.
7. Circle the race of the child/youth, and indicate if they are of Hispanic origin. Provide school details and current grade.
8. Complete the section regarding parents or primary caregivers, including their contact information and whether they are aware of the referral.
9. Outline the child's strengths, interests, and activities. This information helps to tailor support to their needs.
10. Describe the reason for referral and include any safety concerns. This section is vital for assessing the child's needs.
11. For youths aged 12-17, complete the caregiver treatment section, checking all applicable boxes.
12. Document any systems or issues involved with the child/youth, and provide detailed descriptions where asked.
13. List any family and natural support contacts involved with the child/youth. Include their contact information and any known restrictions.
14. If the youth is age 13 or older, ensure their consent is documented by signing and dating the relevant section.
15. Finally, review the completed form for accuracy. Once satisfied, save the changes, and you can download, print, or share the form as needed.

Prepare and submit your (WISe) Referral Form online today to initiate access to essential services.