Care About Me eReferral 
Client Legal First Name *
Client Legal Last Name *
Client Preferred Name
Client Date of Birth *
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Client Contact Information (phone and/or email)  *
Client Preferred Language 
Describe your client’s current situation and the reason for this referral in detail. Please only include sensitive information where relevant to the referral. If the Care About Me team needs additional information regarding this referral, a team member will contact you for more details. *
Please confirm you have discussed Care About Me with the client and they wish to be contacted by Care About Me. 
If you have not discussed Care About Me with your client or your client does not wish to be contacted by Care About Me, Care About Me staff will not reach out to your client. *
Required
Client Insurance (if known)
Is there a day/time that is best for the client to receive a call from a Care About Me Specialist?
Your Name *
What is your contact information (phone and/or email)?  *
What is your relationship with the client? 
What organization are you affiliated with?
Referring Organization Type *

Would you like to discuss this client with a Care About Me specialist prior to the specialist contacting the client? If yes, please provide your preferred day and time for discussion. If no, Care About Me will reach out to the client immediately.

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