Human Services Referral Form | Oneida County, WI

Referring Agency/Organization

Referring Staff Name & Title

Phone

Email

Date of Referral

First Name

Last Name

Date of Birth

Parent/Guardian (if applicable/required if client is a minor or has guardian)

Primary Phone

Secondary Phone (Optional)

Address

Street Address

City

State

Zip Code

Requested Services (check all that apply):

Birth to 3

CLTS (Children's Long-Term Support)

CCS (Comprehensive Community Services)

CSP (Community Support Program)

Psychiatry (Medication Management)

Therapy (Mental Health; Do not select if choosing CCS above)

Substance Use Disorder Counseling or Peer Support (AODA)

Other

Reason for Referral

Additional Notes (Optional)

I understand that by submitting this form I will be contacted to further discuss my request for services to see if my needs can be met by Oneida County Human Services. Further I understand that if staff are not able to reach me directly, they have my permission to contact the person listed above as my contact.

I further understand that participation in any of these services is voluntary and requires a commitment. It will require attending appointments, completing any assignments, and completing documentation that is part of the service programs.

Signature

Date