Referral Form

Guardianship / Representative Payee /Independent Facilitation Referral Form

"*" indicates required fields

Service Requested*

Date*

Name*

First Last

Phone

Email*

SSN

DOB*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Residential Type:*

Guardian/Power of Attorney

(please attach documentation, if applicable)

Name

First Last

Phone

File

Max. file size: 100 MB.

Current Rep Payee:

Name

First Last

Phone

Referral Source

Name

First Last

Phone

Social Security Benefits (Rep Payee Only)

Check all that apply and list benefit amount

SSA Disability Amount $

Pension Monthly Amount $

SSA Retirement Amount $

Tribal Quarterly Amount $

SSI Amount $

Other Amount $

What is the primary nature of the client's disability?

Choose primary disability

If you chose "other" to the above drop down, please describe here:

CMH Services

CM/SC/Therapist

Phone

Other Services

Agency

Case Worker

Phone

Does the person have any criminal charges, past or pending?

If yes, please explain.

Please explain the need for a representative payee and what the current needs are:

Does the person have a history or current substance abuse?

If yes, please explain.

Please list current bills (Representative Payee only):

Rent $

Other $

Electric $

Other $

Gas $

Other $

Water $

Other $

Comments

Referral Completed By

Name

First Last

Agency

Phone

Referral Form

Guardianship / Representative Payee /Independent Facilitation Referral Form

Guardian/Power of Attorney

Current Rep Payee:

Referral Source

Social Security Benefits (Rep Payee Only)

What is the primary nature of the client's disability?

CMH Services

Other Services

Please list current bills (Representative Payee only):

Referral Completed By

stay up to date with our newsletter!