CFTSS Referral Form

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Referral Date

Person Making Referral

First Name

Last Name

Agency Name

Phone #

Email Address

Address

City

State

Zip

Health Home Care Manager Information

*if applicable

First Name

Last Name

Agency Name

Phone #

Email Address

Address

City

State

Zip

Participant Information

First Name

Last Name

Gender

DOB

Caregiver Information

First Name

Last Name

Primary Language

Phone#

Alt Phone#

Email Address

Address

City

State

Zip

County

Legal Guardian Information

First Name

Last Name

Relationship

Primary Language

Phone#

Email Address

Address

City

State

Zip

Participant Health Care Information

Managed Care Plan

Medicaid CIN #

Primary Diagnosis (ICD10)

Secondary Diagnosis (ICD10)

Any Known Safety Concerns?

Referred CFTS Service(s):

Psychosocial Rehabilitation (PSR)

Youth Peer Support and Training (YPST)

Family Peer Support Services (FPSS)

Any additional information that may be important to know:

Any Identified Service Restrictions Surrounding Client Availability:

Additional Resources for Referring Individuals

CCF Medical Necessity Verification (MNV) Form Completed and Signed by a Licensed Practitioner of the Healing Arts (LPHA)

Current Supporting Documentation:

Psychiatric
Psychosocial
Psychological
PSYCKES
Other Pertinent Family Information

		MNV upload...


		MNV upload...

		Supporting Docs upload...


		Supporting Docs upload...

Maximum file size to upload is 10MB.

Uploaded Documents

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