Outpatient Referral Form
Client Name *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Address Where Services Performed *
Medicaid No. *
Current Placement *
If current placement is TFC, Level:
Clear selection
Parent/Guardian/Foster Parent Name *
Relationship to Client *
Parent/Guardian/Foster Parent Phone Number *
Referral Source *
If referral source other, state source
Bill To *
If bill to SCDSS, what county?
Service(s) Needed *
Required
If Diagnostic Assessment required, what is the date of the last assessment?
MM
/
DD
/
YYYY
Services needed by *
MM
/
DD
/
YYYY
Reason for Referral
Submit
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