Representative Payee Program Self Referral Form printable pdf download

Representative Payee Program Self Referral Form

MHA Form I - A

Last Updated Aug 2015 - LB

REPRESENTATIVE PAYEE PROGRAM SELF REFERRAL FORM

MENTAL HEALTH ASSOCIATION

140 NORTH ELM STREET, SUITE A

BUTLER, PA 16001

Phone: (724) 287 – 1965 Fax: (724) 287 – 7090

 All information on this form is considered confidential

Please complete all information

____________________________________________________________________________

Consumer Name: _______________________________ Date:________________________

Referral Source: _____ Self ______Other: (Please Specifiy)____________________________

RESIDENCE: STREET: ________________________________ APARTMENT: ___________

CITY: ____________________________ STATE: ___________ ZIPCODE: ____________

Do you have an alternate mailing address? ________Yes

_________ No

TELEPHONE: (

) _____________________

How long have you been a resident of Butler County? __________________________

SOCIAL SECURITY NUMBER:______ - _____ - ______

BIRTH DATE: ___________________ AGE: _____ SEX: _____ MALE ____ FEMALE_____

Please check all that apply:

MARRIED _____ SINGLE _____ DIVORCED _____ SEPARATED _____

WIDOW / WIDOWER _____ SERVED IN MILITARY___________

PAYEE STATUS:

Please describe the reason for request of payee services:

______________________________________________________________________

_____ This is expected to be a short term service.

_____ This is expected to be a long term service.

_____ There is a current payee:

Name: ________________________ Telephone: (

) ___________

Relationship to consumer: _____________________________________

_____ This a new payee request

Have you ever had Representative Payee Services before? _______YES _______NO

Has MHA of Butler County ever provided Payees Services to you before? _____YES _____NO

Do you have a guardian? _________ YES __________ NO

Representative Payee Program Self Referral Form