Get the free Client Referral & Pre-screening Form

This form is utilized for client referrals and pre-screening for Withdrawal Management Services (WMS). It collects essential client information, admission criteria, substance use history, medical and mental health details, and consent for referral process, ensuring that clients meet safety and suitability requirements for admission to WMS.

How to fill out client referral pre-screening form

How to fill out client referral pre-screening form

1. Start by collecting basic client information such as name, contact details, and date of birth.
2. Include demographic information like gender, ethnicity, and language preferences.
3. Ask for the client's reason for referral and any specific issues they need assistance with.
4. Include medical and psychological history relevant to the referral.
5. Request information about current medications and any ongoing treatments.
6. Provide space for the referrer to include their details and the relationship to the client.
7. Ensure the client signs the form to authorize the release of their information.
8. Review the completed form for any missing information before submission.

Who needs client referral pre-screening form?

1. Healthcare providers looking to assess a client's needs before a full evaluation.
2. Social workers and case managers in need of preliminary information for service planning.
3. Mental health professionals requiring background information on potential clients.
4. Organizations that facilitate referrals for specialized services.
5. Insurance companies needing pre-screening to approve coverage for services.

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What is client referral pre-screening form?

The client referral pre-screening form is a document used to evaluate potential clients before they are officially accepted into a program or service. It helps organizations assess eligibility and suitability.

Who is required to file client referral pre-screening form?

Typically, clients who are seeking to access specific services or programs must submit a client referral pre-screening form. This requirement may vary depending on the organization or program.

How to fill out client referral pre-screening form?

To fill out the client referral pre-screening form, provide all requested personal and contact information, details about the client's situation, and any necessary documentation that supports the referral.

What is the purpose of client referral pre-screening form?

The purpose of the client referral pre-screening form is to gather essential information to determine whether a client qualifies for services or programs, ensuring proper fit and resource allocation.

What information must be reported on client referral pre-screening form?

The form typically requires personal identification details, contact information, circumstances surrounding the referral, and any relevant medical or social history pertinent to the assessment.