04mp001e 2026

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4.8 out of 5

162 votes

The document is a referral form used by Child Welfare (CW) or Comprehensive Home-Based Services (CHBS) workers to refer clients for substance abuse assessment and treatment services. It requires detailed client information, reasons for referral, and observable behaviors indicating substance abuse that may put children at risk. The form must be completed for each client and includes sections for signatures from the referring worker and supervisor.

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Click ‘Get Form’ to open the 04mp001e in the editor.
Begin by filling in the 'To' section with the appropriate recipient's details, followed by the date of referral.
In the 'Identifying Information' section, enter the case name, county, and family's street address, including city, state, and ZIP code.
Provide the KK number as it is essential for processing this referral.
For the 'Client Referred for Services' section, input the client's first name, middle initial, last name, date of birth, gender, and race.
Indicate eligibility by confirming that the client's income and resources are insufficient for services.
In 'Reason for Referral', detail specific indicators of substance abuse and whether it is drug-related or alcohol-related. Include observable behaviors and any relevant history.
Finally, ensure both referring CW/CHBS worker and supervisor sign and date the form before submission.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (162 Votes)
2006	4.3 Satisfied (120 Votes)

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