Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to access the document and open it for editing.
2. Begin by filling out the client information section. Provide the client's full name, date of birth in a month/day/year format, and current street address, including city. Ensure accurate Social Security number input.
3. Indicate marital status by selecting the appropriate option: single, married, widowed, divorced, separated, or other. Additionally, specify the client's race/ethnicity from the provided options.
4. Next, enter contact information. Include home and work phone numbers. If applicable, record information for the agency or school, including their respective phone numbers.
5. Fill in the contact information for the parent(s)/guardians, emergency contact, case manager, school contact, psychiatrist, therapist, and any other relevant individuals.
6. Provide any known diagnosis related to the client's situation in the diagnosis field.
7. Select the payment options and insurance information applicable to the client. If medical assistance is available, include the relevant numbers. Choose any appropriate insurance providers listed.
8. Clearly describe the presenting issues that necessitate the client's referral in the designated section.
9. Indicate the specific services requested from the provided list. Mark options such as waivered services, in-home support, mental health services, among others.
10. Complete the service start date, hours per week authorized, and anticipated length of service fields.
11. Finally, have the referring staff or case manager sign and date the form, including their contact number. Review all entries for accuracy.
12. Once completed, save the changes, download the file, print it for your records, or share it as needed.

Begin filling out the Metro Social Services Client Referral Form online today!