REFERRAL FORM - Milwaukee County
|[pic] | |
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| |Behavioral Health Division |
| |of Milwaukee County |
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| |Service Access to Independent Living |
Recovery Support Service Referral Form
The purpose of this form is to initiate the referral process. A Service Authorization Request has been submitted to the Behavioral Health Division (BHD). BHD reserves the right to deny any service request. If and when this service is approved, the authorization confirmation will be faxed to you.
Date / /
|Referred by: |
| |
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|Name of Recovery Support Coordinator Name of Agency |
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|Phone (414) Pager (414) |
| |
|Name of Provider/Agency being referred to: |
| |
|Address |
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|City State WI Zip |
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|Name of Provider Contact Phone (414) |
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|Service Being Requested: Service Code: SC |
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|Frequency Requested (Date Span and Units): |
Name of Person Referred: Phone (414)
Address
City State WI Zip
Ethnicity: African American Caucasian Hispanic
Native American Asian Other
Gender: Male Female DOB: / /
Special Accommodation Needs, if any: (i.e., physical disabilities, medical needs, limitations, etc.)
Emergency Contact: Home Phone ( )
Address Work Phone ( )
City State WI Zip
Relationship to Client
Siblings/Children:
1. DOB / /
2. DOB / /
3. DOB / /
4. DOB / /
School Not Attending Not Attending NA
Grade(s) Special Education: Yes No
GENERAL INFORMATION
Needs/Reason for Referral:
Safety Concerns:
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