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Appendix: Example of Referral Form


Rio Arriba County Health and Human Services Referral Form

Date:__________________

Client Name:______________________________

Client Social Security #:______ - ______ - ______

Referring Agency:____________________________________

Referred To:________________________________________

For the following services:

____________________________________________________

____________________________________________________

____________________________________________________

_____________________________________
Client Signature
__________________
Date
_____________________________________
Counselor
__________________
Date

Please attach a copy of the client's Authorization to Release to Referral form.