Follow the steps to accurately complete the referral form.

1. Press the ‘Get Form’ button to access the referral document and open it in your preferred editor.
2. Fill in the child or youth's information in the designated fields. Include their last name, first name, middle initial, date of birth, age, provider one number, and address details, including apartment number, city, state, and zip code. Indicate if the individual has had a CANS screen in the last 30 days by selecting 'Yes' or 'No'.
3. If applicable, include information for the social worker, such as their name and best contact information.
4. Provide the primary parent or guardian's details. Fill out their last name, first name, relationship to the client, and address, along with the best contact number. Indicate whether the primary guardian has physical custody, legal custody, and if they are an emergency contact. Include the best time to call and the email address.
5. Complete the referring agency information section by filling in the agency name, provider name, and phone number. Specify if the referral is for CLIP/PCCA services by choosing 'Yes' or 'No'.
6. Identify any relevant risk factors by checking all that apply. This includes options such as physical aggression, past suicide attempts, drug abuse, suicidal ideation, and more.
7. Add any additional notes or reasons for the referral in the designated area for further context.
8. Once all fields have been filled out accurately, save the changes made to your document. You may choose to download, print, or share the completed form as necessary.

Complete your WA Excelsior Wellness WISe Referral online today to ensure timely access to necessary services.