Your First Name
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Your Last Name
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Referring Agency
Referrer Phone Number
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Area Code
Phone Number
Referrer Email
example@example.com
Referring To:
CSSA
CSMH
ERCS
Day Support
Day Rehab
BHEP
Participant Information
Referral First Name
Referral Last Name
Address
City
State
Zip
Social Security Number
Phone Number
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Area Code
Phone Number
Birth Date:
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Month
-
Day
Year
Date
Gender
Male
Female
Diagnosis:
Include required ICD 10 codes
Diagnostic Impression
Clinician/Provider:
Problem Areas:
Primary Support Group
Primary Support Group
Problems w/access to Health Care
Legal Issues
Education Problems
Social Environment
Occupational Problems
Economic Problems
Other Psychosocial and Environmental Problems
Housing
Reason for Referral
Why now? What is the presenting problem and why is it necessary for services now? How is the presenting problem affecting their mental health symptoms/recovery? What are the specific symptoms that are creating the need for these services?
Type a question
Goodwill Service Location
Select Your Goodwill Service Location
Grand Island Service
Columbus
Broken Bow
Attach Required Documentation
A copy of your Release of Information and a copy of the most recent Psychosocial Assessment, Diagnostic Impression, or Pre-Treatment Assessment. Current medication list, if available. Medicaid Service Definitions prevent Goodwill from providing Community Support and/or Day Services programming without first obtaining these necessary documents. *Please include a Release of Information for Vocational Rehabilitation when making referral for Supported Employment.
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Referring Signature
Date
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Month
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Day
Year
Date
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