NCS Referral Form

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NCS Referral Form

To access our quality services, please tell us a little about yourself. We review each assessment with the intent to match individuals need with the most suitable and effective service.

Date Today *

YYYY

First and Last Name *

Date of Birth *

YYYY

Age *

Gender *

Male

Female

Prefer not to say

Race *

Medicaid# (12 Digits) *

School

Parent/Guardian/Payee *

Phone *

Email *

Address *

Brief Description of Current Problems and Services *

Check or List appropriate services being currently received *

Intensive In-Home

Outpatient Therapy

Case-Management

Mental Health Skill-Building

Group Home

Substance Abuse IOP

Partial Hospitalization

DD Waiver Services

Other:

Required

Check or List services being requested *

Intensive In-Home

Outpatient Therapy

Case-Management

Mental Health Skill-Building

Group Home

Substance Abuse IOP

Partial Hospitalization

DD Waiver Services

Placement in Sober Living Home

Other:

Required

Eligibility and Documentation (One of the following three must apply for eligibility) (Please Circle # that applies)
*

Has difficulty in establishing or maintaining normal personal relationships to such a degree that he or she is at risk of hospitalization or out-of-home placement because of conflicts with family or community.

Exhibits such inappropriate behavior that repeated interventions by the mental health, social services, or judicial system is necessary.

Exhibits difficulty in cognitive ability such that he or she is unable to recognize personal danger or recognize significantly inappropriate social behavior.

Required

Referring Person and Agency (If Applicable) *

Agency (if applicable) *

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