CORE/Medicaid Referral Form
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Date: *
年
/
月
/
日
Caseworker (or name of referring individual): *
Telephone/Fax#: *
County office (or referring agency): *
Email Address: *
Referral Source: *
必填
Service to be provided: *
必填
Reasons for referral: *
必填
Additional comments: *
Name of Primary Caregiver: *
Email: *
Contact Number: *
Address: *
City/Zip: *
Name of Consumer: *
School/Grade: *
Medicaid#: *
 Medical Plan: *
DOB: *
年
/
月
/
日
Has Consumer been diagnosed or has a suspected Mental Health or Substance Abuse Disorders? *
Please fax Psychological and/or Psychiatric Assessments to: 770-918-8800
Check all that apply: *
必填
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