MIKID Referral Form | M.I.K.I.D.

M.I.K.I.D Referral Form

Section A : General Member Information

Today's Date

Member's Full Name (Medicaid Name)

Date of Birth

Medicaid Number

Gender

Male

Female

Prefer Not to Say

Other (Specify)

Member lives with

Bio

Foster

Kinship

Other (Specify)

Member's Address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Guardian / Contact Full Name

Guardian Phone #

Submitter's Email Address

Preferred Method of Contact

Phone Call

Text

Best Time to Contact

Morning

Afternoon

Evening

Additional Member Information

Placement Name

Placement Phone #

PCP Details (Name, Address and phone Number)

PCP Name

PCP Address

Country/Region

Address

Address - line 2

City

Zip / Postal code

PCP Phone #

Member's Behavioral Health Home and Office

No BHH

Case Manager Name

Case Manager's Email

Case Manager Phone #

Section B – Services Interested In

Services Interested In:

Counseling

Family Support

Child Based Services (Respite, Skills, Group, TAY)

Other

Section C - Consent and Submission

Acknowledgement / Consent to Treat / Release of Information

By signing below, I grant permission to Mentoring & Inspiring Kids In Development to provide services as may be deemed necessary or advisable for the care of:

Member Name

Guardian Signature

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Date

Verbal Consent Given By (full name & relationsship to child):

Date

Submission instructions

Complete the required fields (*) and save a copy of this form.
Submit the completed form through MIKID's approved secure referral process.
A website submission button and automatic confirmation emails require website configuration.
Do not email sensitive member information through unsecured email.

*For Behavioral Health Agency referrals ONLY:

Services cannot start until the following documentation is email to referrals@mikid.org

Assessment
Service Plan
CALOCUS
Crisis Plan

Referral inbox: referrals@mikid.org