988 Referral

988 Staff Access

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	Request for Behavioral Health (Mental Health or Substance Use) Assessment and/or Linkage with Family Service League, Inc.

Date

Requestor's Contact Information

First Name

Last Name

Callback Number

Email Address

Secondary Contact Information (i.e. if need to reach different staff member your shift is complete, etc.)

First Name

Last Name

Callback Number

Email Address

Referral Information

Referral Type

Mental Health

Substance Use

Mental Health & Substance Use

Referral Reason

Is this a first time caller to 988?

Client's Information

First Name

Last Name

Address

City

State

Zip

SSN

DOB

Language

Gender

Gender Identity

Race

Legal Guardian Contact Information (If a Minor)

First Name	Last Name	Relationship	Phone

First Name

Last Name

Phone #

Relationship

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988 Staff Access

Request for Behavioral Health (Mental Health or Substance Use) Assessment and/or Linkage with Family Service League, Inc.

Requestor's Contact Information

Secondary Contact Information (i.e. if need to reach different staff member your shift is complete, etc.)

Referral Information

Client's Information

Legal Guardian Contact Information (If a Minor)