Children Services Special Population Access Screening

Children Services Special Population Access Screening

Purpose: For Children Providers to submit Consumer Enrollment Packet to DWIHN Access Center for special population services.

Child Name*

Children Provider Name*

Staff Name*

Staff Email*

Screening Date & Intake Assessment Date*

Does your agency plan to complete the Screening Date the same day as the Intake Assessment Date?

If yes, email DWIHN Access Department representatives Tracy Mancini/tmancini@dwihn.org and Anthony Edwards/aedwards@dwihn.org requesting to provide MHWIN ID# the same day.

Select

Screening Date*

COFR Case*

Is this a COFR (County of Financial Responsibility) Case?

Select

COFR Comments*

Provide explanation.

Special Population*

Select which children special population is applicable (can select more than one).

Select

Disability Designation*

Select

Upload the Consumer Enrollment Packet & Proof of Residency documentation.*

Drag and drop files here or

Additional Comments

Send me a copy of my responses

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