Referral Form

Woodward Community Based Services

SCL – BI/ID WaiverHBH HOURLYHBH DAILY

Please provide social history and most recent service plan with referral form.

Name:

DOB:

Age:

Gender:

Race:

Title XIX:

SS#:

Religion:

Preferred Language/Communication:

School/Employer:

Current placement/residence:

Address:

Phone number:

Email:

Guardian(s):

Address:

Phone:

Preferred Language:

Email:

Mother:

Phone:

Address:

Father:

Phone:

Address:

Emergency Contact:

Phone:

Relationship to Member:

Referral Source:

Phone:

Agency:

Funding Source?:

Private Pay?:

Sliding Fee Scale?:

Medical Conditions:

Impairments (If Any):

Allergies:

Medications: Mental Health Diagnosis: Expected tier level/weekly service hours (Hourly/SCL): Insurance Information Please provide a copy of your insurance card(s) prior to your appointment by sending it to madison.bates@wcbscares.com or bring a copy with you for your intake.

Primary Insurance Coverage:

Phone Number:

Name of Insured:

Insured DOB:

Relationship to Insured:

Insured Employer:

Policy #:

Group #:

Effective Date:

Secondary Insurance Coverage:

Phone Number:

Name of Insured:

Insured DOB:

Relationship to Insured:

Insured Employer:

Policy #:

Group #:

Effective Date: