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Type of Referral
Type of Referral:
Self-Referral (Complete Section A & B)
Underinsured/uninsured Referral (Complete Section A)
PSN Referral (Complete Sections A & C)
JD#
Probation# (If applicable)
Today's Date
*
Member's Full Name (Medicaid Name)
*
Date of Birth
*
Medicaid Number
AHCCCS Number
Gender
*
Choose one
Member lives with:*
Member lives with:
*
Bio
Foster
Kinship
Other
Member's Address
Country/Region
*
Address
*
Address - line 2
City
*
Zip / Postal code
*
Guardian Name
Guardian Phone #
Placement Name
Placement Phone #
PCP Name
PCP Address
Country/Region
*
Address
*
Address - line 2
City
*
Zip / Postal code
*
PCP Phone #
Member's Behavioral Health Home and Office
Check If No BHH Assigned
Case Manager Name
Case Manager's Email
Phone #
Fax #
Section B
Requested services (list all that apply)
T1016 Case Management
S5110 Family Support
S5110HQ Family Support Group
T1019 Personal Care
S5150 Unskilled Respite
H2027 Pre-Job Training
H2027HQ Group Pre-Job Training
H2025 Ongoing
Support to Maintain Emp
H2025HQ Group Ongoing Support to Maintain Emp
T1013 Interpretive Services
H2014 Individual Living Skills
H2014HQ Group Living Skills
H0038 Individual Peer SupportOption 14
H0038HQ Group Peer Support
H0025 Individual BH Prevention/Ed
H0025HQ Group BH Prevention/Ed
H0004 Individual Counseling
H0004HQ Group Counseling
A0120 Trans-Base
S0215 Trans-Mileage
Section C - PSN Referral Only
JD#
Date of Removal
Hiring Removal
Parent 1 Information
Full Name
Medicaid Number
Date of Birth
Parent's Contact #
Address
Parent 1 Address
Country/Region
Address
Address - line 2
City
Zip / Postal code
Contact Type
Phone Call
Text Message
Voicemail
Best Time to Call
Morning
Afternoon
evening
Parent 2 Information
Full Name
Medicaid Number
Date of Birth
Parent's Contact #
Parent 1 Address
Country/Region
Address
Address - line 2
City
Zip / Postal code
Contact Type
Phone Call
Text Message
Voicemail
Best Time to Call
Morning
Afternoon
evening
Attorney Name (Mother)
Contact #
Attorney Name (Father)
Contact #
Attorney Member
Contact #
DCS Case Worker
Contact #
Ongoing Case Manager
Contact #
Services cannot start until the following documents are received: Please email this referral form to: referrals@mikid.org with the following documentation.
Request for services page
Behavioral Health referral page
Assessment
Service Plan
ROI
Family Support (S5110)
Unskilled Respite (S5150)
Case Management (T1016)
Parent Signature
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Date
Verbal consent given by (full name & title):
Date
Submit referral
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