Dhs Referral Form - Morrison Child & Family Services
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1OREGON DEPARTMENT OF HUMAN SERVICES (DHS)
REFERRAL FOR MORRISON OUTPATIENT SERVICES
PLEASE FAX COMPLETED FORM TO
(with RELEASE OF INFORMATION)
CENTRAL INTAKE AT (503) 872-0659
or call Intake Call Center Phone # (503) 258-4381
___Oregon Health Plan #
Client:
DOB:
___ Uninsured
(if so, pls include the info below)
Hshld income__________ #of in hshld
____________________________________________________
____
*MCFS requires clients be eligible for OHP
__
Date of Referral: _________________________
Legal Guardian: _____________________________ Relationship to client____________ Phone #
Person child lives with: _______________________ Relationship to client____________ Phone #
Client’s address:
Client’s school:
Parent/caregiver is aware of this referral and agrees to being contacted by Morrison? ___ Yes ___ No
Will family need a Spanish-speaking therapist? ___ Yes ___ No
Will family need other language interpreter services? ___ Yes ___ No If Yes, which language?
Referring DHS CMC/CW Name & Phone #: ____________________________________________EXT#
Branch:
Gresham
N/NE
St. Johns
Other:
New Market
Midtown
East
Service(s) Requested:
Outpatient Mental
Outpatient Substance
Family Sexual Abuse
Counterpoint
Health
Use Services (ISUS)
Treatment (FSAT)
Outpatient (CPOP)
Identified Concerns/Observations:
Client’s Primary Care Physician: ________________________________________Phone No.
Significant illness/health information:
Medications:
Morrison Site requested:
Irving
Gresham
Knott Office
Beaverton (WashCo)
Oregon City (ClackCo)
1500 NE Irving, #250
912 NE Kelly Ave, #200
11456 NE Knott
14025 SW Farmington Rd. #160
1713 Penn Lane, Ste B
Portland, OR 97232
Gresham, OR 97030
Portland OR 97220
Beaverton OR 97005
Oregon City, OR 97045
(503) 258-4555
(503) 258-4600
(503) 736-6500
(503) 258-4495
(503) 258-4545
MORRISON CALL CENTER STAFF WILL CONTACT PARENT/GUARDIAN
TO SCREEN AND SCHEDULE INTAKE APPOINTMENT
This form is available on-line for download at
– click on “Intake”
cr. 5-07, R 10/08, 2/11, 5-11, 6/11, 11/12, 1/14
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Parent category: Legal