Get Youth Referral Form For The Cases Nathaniel Clinic - Cases

Filling out the Youth Referral Form for the CASES Nathaniel Clinic is an important step in accessing necessary mental health services. This guide will help you navigate the form accurately and thoroughly to ensure a smooth referral process.

Follow the steps to fill out your form with ease.

1. Click the ‘Get Form’ button to obtain the referral form and open it in your preferred document editor.
2. Enter the date when the referral is being made in the designated field at the top of the form.
3. Indicate whether the client is currently receiving mental health treatment elsewhere by marking 'Yes' or 'No'.
4. Fill in the client's name, age, date of birth, and gender in the provided fields.
5. Provide the client's primary phone number and an alternate contact number.
6. Insert the client's home address in the specified section of the form.
7. If the client is under 17 years old, include the parent's name along with their phone number and alternate contact information.
8. Document the best time and method to contact the client, ensuring clarity for follow-up communication.
9. Complete the referral agency information, listing the agency's name and phone number.
10. Identify the type of agency making the referral by checking the appropriate box.
11. If urgent care is required, mark 'Yes' and provide details if any listed categories apply to the client.
12. Outline the services being requested by checking the relevant options for criminal justice referrals and other services.
13. Fill in any necessary identification numbers, such as the New York State Identification number or other relevant identifiers.
14. If applicable, note the client's next court date and current legal status or conditions of release.
15. In the reason for referral section, describe the client's needs in detail, covering mental health, trauma, and any relevant social services.
16. Answer questions related to the client's tobacco use, current therapy, hospitalization history, and medication use.
17. Provide information about insurance status, including Medicaid/Medicare details or current application status.
18. List any necessary documents needed for a complete referral checklist.
19. Remember to include any required screening tools by checking the relevant boxes.
20. Finally, fax the completed referral form and supporting documents to the clinic’s designated fax numbers provided on the form.

Start filling out the Youth Referral Form online to provide essential support for the client.