Get Cps Program - Client Referral For Certified Peer Specialist Program 04-09-14docx

This guide provides a step-by-step approach to completing the CPS Program referral document online. It aims to assist individuals in accurately filling out the form to ensure timely and efficient processing of peer support services.

Follow the steps to accurately complete the CPS Program referral form online.

1. Press the 'Get Form' button to access the CPS Program referral form and open it in your preferred online editor.
2. Begin filling out the personal information section, which includes the individual's name, address, city, phone number, and date of birth (DOB). Ensure that all fields are completed accurately.
3. Determine the Medicaid eligibility of the individual. Select 'Yes' or 'No' as appropriate. This information is crucial for the referral process.
4. In the section related to military service, indicate whether the individual is or was a member of the U.S. Armed Services by selecting 'Yes' or 'No'.
5. Complete the fields for the person providing the referral, including their name, position, address, phone number, company or organization, and email.
6. Enter the name and contact information of the primary care physician associated with the individual being referred.
7. Document the diagnoses using the Axis I-V format, ensuring that valid codes and descriptions are included as per the specified mental health criteria.
8. In the treatment history section, select one of the categories (A, B, C, or D) that apply to the individual. Provide detailed information as requested.
9. The practitioner must sign and date the form to attest to the accuracy of the referral information. This signature confirms the recommendation for peer support services.
10. Finally, review all information provided for accuracy, then save changes, download, print, or share the completed form as required.

Complete your documents online to ensure a smooth referral process.