Utah's Department of Workforce Services Referral for Services Form. Employment counselors use the Referral for Services form to link clients with mental health and other services such as medical, housing, transportation, and legal services. Employment counselors send the forms to the Department of Workforce Services social worker assigned to the local welfare office. Social workers may also use this form to access mental health treatment for the client. The form takes approximately 10 to 15 minutes to complete.
Tennessee's Family Services Counseling (FSC) Referral Form. Tennessee's FSC Referral Form was developed exclusively for the FSC program. Employment case manager complete this two-page form to refer a client to the FSC program. The form includes basic demographic information, reason for referral, referral source, TABE test results, the employment case manager's name, and potential barriers to employment. The form takes between 20 and 25 minutes to complete.
Florida's TANF SAMH Program Certification (Referral) Form. Contracted service providers use this form to obtain authorization to provide mental health and substance abuse services to TANF recipients and other low-income families. Clients may be identified by outreach workers or referred directly to contracted service providers for mental health and substance abuse treatment. Contracted service providers complete this referral form and fax it to the TANF SAMH district specialist for approval. The form takes 10 to 15 minutes to complete.
Florida's TANF SAMH Services and One-Time Payment, Purchase of Service, Request/Approval Form. Florida's TANF SAMH specialists monitor and approve the services provided through the contracted TANF SAMH treatment agencies. Every six months, a TANF SAMH specialist reviews each case. These specialists are given wide latitude in deciding which services should be provided and for how long.
Referral forms for all sites [in PDF format]