Follow the steps to complete the form effectively.

1. Select the ‘Get Form’ button to access the referral form and open it for completion.
2. Enter the referral date in the designated field at the top of the form. This helps in tracking the timing of the referral.
3. Input the Medicaid number, ensuring that it is accurate to facilitate any required insurance processing.
4. Provide the individual's full name followed by their date of birth in the respective fields. This information is essential for identification.
5. Select the gender by marking either 'M' for male or 'F' for female. This may be used for demographic purposes only.
6. Indicate the county of residence, which is important for determining eligibility for local resources.
7. Fill in the home and cell phone numbers to ensure that the referral team can contact the individual or their family.
8. Choose the primary language from the available options: English, Spanish, or Other to assist with communication needs.
9. Answer the eligibility questions regarding the client’s stability at home, co-morbid conditions, and safety concerns by marking 'Y' for yes or 'N' for no as applicable.
10. Specify any relevant diagnoses by providing details for mental health, substance abuse, and chronic medical conditions in the corresponding fields.
11. Describe the crisis in detail so that the referral center can understand the urgency and nature of support required.
12. Complete the referral source section by filling in the name of the referral agency, its address, and the person's contact details making the referral.
13. Review the form for completeness and accuracy, ensuring all required fields are filled out correctly.
14. Once completed, save the changes, and then you can choose to download, print, or share the form as needed. Remember to fax the completed form to (315) 820-0191 or call (315) 280-0384 for any inquiries.

Take the first step towards receiving support by completing and submitting the form online today.