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Local Department of Social Services Client Referral Sheet

Full Name of Client: __________________________________________________

Address: __________________________________________________________________

City/County ___________________________________________Zip Code: ___________

Client Case #: __________________________ Time-Limited: ________yes _________no

Referred To: _______________________________________________________________ (Name of Re-entry Services Coalition Member)

Services requested: __________________________________________________________

__________________________________________________________________________

Local Social Services Agency: ________________________________________________

Person Referring: ___________________________________________________________

Signature of Person Referring: _______________________________Date:____________

Phone Number: (_____) ______-____________ FAX: (_____) ______-_____________

Email Address: _______________________________________

Authorization to release information: Confidentiality: Any information obtained by the Re-entry Services Coalition concerning recipients of social services shall be treated as confidential in accordance with relevant provisions of State and federal law.

Client Signature: ________________________________________Date_______________

*Person Receiving Client: ___________________________________________________

Signature of Staff Receiving Client: _____________________________Date:_________

*Client Referred to One-Stop: ____yes ____no Date: _________________________

*Local department of social service worker making referral must be notified via e-mail.

032-03-0412-02-eng (9/2009)