Client Referral Form – CCM-4U Intake Services Client Information Full Name: Date of Birth: Phone Number: Email Address: Home Address: Preferred Contact Method: Phone Email Text Primary Language: Interpreter Needed: No Yes Referral Source Referring Person / Agency Name: Role / Relationship to Client: Phone Number: Email Address: Agency Address: Reason for Referral Brief Description: Services Requested: Housing support Transportation assistance Mental health coordination Substance use support Medical appointment coordination Social services navigation Benefits assistance Other: Client Needs & Background Current Living Situation: Homeless Staying with family Renting Shelter Transitional housing Other Primary Challenges: Medical Behavioral health Social Financial Safety Other: Emergency Contact Name: Relationship: Phone: Risk or Safety Concerns Safety Issues: Is the client currently in crisis? Select No Yes Insurance Information Insurance Type: Select Medicaid Medicare Private Uninsured Member ID: Primary Care Provider: HIPAA Authorization I authorize CCM‑4U to share and coordinate my PHI for case management services. Client Consent I consent to participate in Community Case Management services through CCM‑4U. Electronic Signature Typed Name: Date: Submit Securely
