Get Outside Referral Form - Semo

This guide provides comprehensive instructions on completing the Outside Referral Form - Semo online. Following these steps will ensure that you accurately fill out all required sections and provide the necessary information.

Follow the steps to successfully complete the referral form.

1. Press the ‘Get Form’ button to access the Outside Referral Form and open it in your preferred online editor.
2. Begin by filling in the client’s full name in the designated field. Ensure that you provide the correct information as this is vital for identification purposes.
3. Next, enter the client's date of birth (DOB) in the appropriate section. This helps in verifying the client's age and eligibility for certain services.
4. In the field provided, input the name of the parent or legal guardian. This is important for contact and authorization purposes.
5. Enter the primary phone number of the client or the parent/legal guardian in the specified area to facilitate communication.
6. Complete the client’s address, including street, city, state, and zip code. Accurate address details are essential for service delivery.
7. In the 'Other Contact Information' section, provide any additional contacts available for the client, ensuring consistency in communication.
8. Fill in the referring person's name and phone number in the appropriate fields. Specify the agency they are associated with, if applicable.
9. Select the position of the referring individual from the provided options. This will help in understanding the context of the referral.
10. Indicate the reason for referral by selecting relevant options from the list provided. This section outlines the client's needs and guiding factors for the referral.
11. If there are specific diagnostic services needed, mark the applicable boxes to assist in determining the client’s requirements.
12. Include any screenings completed, such as M-CHAT or SRS2, and provide the scores. This information is critical for assessment.
13. Document the current diagnosis and pertinent medical history in the designated fields. This section should include all relevant details.
14. Ensure a signed prescription for Speech and Language Evaluation and Treatment is included, if required, along with the physician's signature and date.
15. Once all sections are completed, review the information for accuracy. You can then save the changes, download, print, or share the form as necessary.

Complete your Outside Referral Form - Semo online to ensure seamless processing of services.