New MACC REFERRAL FORM

*Please Note

Once you start filling the form, you cant save it and continue later. Please go through the form before filling it to ensure you have all the information required.

Date of Critical Incident

Staff has been informed someone from MACC will contact them?

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Have You Made or Planning to Make a Referral Elsewhere?

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New Directions Service Area*

Please select all options that apply

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Relationship to Individual

(Ex. Self, Case Manager, Social Worker, Friend, Parent, etc.)

Individual's Social Worker or Community Services Worker (if applicable)

Agency

*If applicable

Agency Contact Person

First & Last Name

Known Health Conditions

Please describe any Known Health Conditions(e.g. Physical, Mental Health Diagnoses, Allergies)

Guardian or Substitute Decision Maker

Please indicate the name, email & Phone # of the Guardian/SDM. (*If applicable)

What Questions Do You Hope To Get Answered? What do you hope to get out of the services you are requesting?*

What supports are required: (you can select more than one)

Financial Information

Please contact macc@newdirections.mb.ca or 204 786 7051 ext. 2560 for questions about funding.

Name of Insurance Company

Blue Cross, GWL, Sunlife, Other.

Funding Agency*

Do you have funding through a third party?

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Send Invoice to the attention of:

First and Last Name

Contact Information*

Phone and Email

File Upload*

*Attach Consent Form

Drag and drop files here or

Acknowledgement of Information*

I hereby acknowledge that the consent form attached to this electronic form has been signed by the individual who will receive services or their substitute decision maker/guardian.

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Acknowledgement of Information*

I hereby acknowledge that the information provided in this referral is true to my best knowledge.

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*Please Note

Training Section

Consultation: Staff Debriefing

Section 1

Section 2

Section 3

Information About the Individual Receiving Services

Financial Information

Final Section