Form Dss-8224 - Work First Program Referral To Qualified Professional In Substance Abuse - North Carolina

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WORK FIRST PROGRAM REFERRAL TO QUALIFIED PROFESSIONAL IN SUBSTANCE
ABUSE
This referral must be completed when making a referral for a Work First Program applicant or recipient for further
assessment by a Qualified Professional in Substance Abuse.
Referring Agency Information
County Name __________________________________ Date of Referral ____________________
Person making referral ___________________________ Title _____________________________
Telephone No. _____________________ Email _________________________________________
□
Please contact me for more information.
□
Contact me with appointment time for the person referred.
□
Contact me if the person does not keep appointment.
Applicant/Recipient Information
Name of Person being referred: ____________________________ PDC#: ____________________
Mailing Address: ________________________________________
______________________________________________________
________________________
City
State
zip code
Telephone Number
Signed Consent for Release of Confidential Information (DSS-8219) Attached
□
□
yes
no
Substance Use Information given to applicant/recipient
Reason for Referral
Mandatory*
Optional+
Mental Health Assessment or Referral to LME-MCO for Assessment
Assessment due to AUDIT Screening
Assessment due to H & I Felony (North Carolina)
Determination of Satisfactory Completion of Substance Use Treatment
Determination of Satisfactory Participation in Substance Use Treatment
Information and Referral Regarding Substance Use Disorders and Treatment
*
Mandatory- Referral is an eligibility/program requirement. Applicant/recipient compliance is a condition of
eligibility.
–
+Optional
Applicant/recipient compliance is not a condition of eligibility.
Comments:______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
DSS-8224 8/2015
Economic and Family Services
The North Carolina Division of Social Services does not discriminate against any person on the basis of race, color, national origin,
disability, sex, or age in the admission, treatment, or participation in its programs, services and activities, or in employment.

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