PM 02-02-00.
Use the Referral Form (Form 2151) to make, monitor, and document a referral for services to another agency or to any other area within DHS. Use the form anytime a referral is needed except for referrals to ORS or DoA when the client needs to provide care to a person who is not a related child under 18 or a spouse. In those situations, use Referral for Assessment (Form 4647). See WAG 21-01-04-d.
Form 2151 can be completed manually or by completion of the appropriate windows in the Resource Directory and Connections (RD&C) in the Virtual Case Manager (VCM) system.
The manual version of Form 2151 contains a list of potential sources who can provide services depending on the person's specific needs. Familiarize yourself with the list and how it relates to the referral sources in your Family Community Resource Center area.
Form 2151 contains a section that is completed by the source to whom the client was referred. The form is to be returned to the Family Community Resource Center within 48 hours of the appointment date. Monitor the results of the referral from information reported by the provider.
Form 2151 contains a consent to release of information. Be sure to explain the following to the applicant/client:
- who the information is being released to;
- the information that will be included with the release (e.g., date, type of services including treatment recommendations, compliance status, schedule of activities, ability to engage in work activities, work schedule, supportive service needs, justification);
- that the consent is valid for one year from the signature date, unless revoked in writing; and
- that the information may not be shared with any other persons without additional written consent.
Make sure the client signs and dates all copies. Check all appropriate boxes and answer any questions the applicant/client may have concerning the release.
Remember that if more than one provider is involved, separate releases of information must be obtained for each. For example, the counseling center completes the assessment, but treatment services are provided by another mental health agency.
Once a referral has been made, providers are required to submit a progress report on the client's progress every 30 days or within 48 hours of a significant change. The progress report to be used depends on the nature of the referral.
Use the Change Progress Report Form - Specialized Response (Mental Health, Substance Abuse, Domestic 
or Sexual Violence) (Form 2151B) to facilitate communication between providers of mental health, substance abuse, domestic and sexual violence services and DHS. Use the Teen Parent Services Change/Progress Report Form (Form 2151D) to facilitate communication between TPS and the Family Community Resource Center. Use the Change/Progress Report Form (Form 2151A) to facilitate communication between all other providers and DHS.
The forms are used not only to communicate the client's progress, but to identify when there may be a need for a change. In addition to using the forms, more direct contact between the agencies may be needed (e.g., a phone call, meeting, joint staffing).
The Change Progress Report Forms are used to report information from DHS to a provider and from a provider to DHS.
Following through on a referral is only required for TANF cases that contain an adult and the referral is included as part of the RSP. When you make a referral, include the referral as part of the RSP. Following through on a referral is not a requirement for child-only TANF or any other category of assistance.
