Please use this form to complete a referral to our Social Worker and provide some background information about your reason for the referral. The information you provide intended for the sole use of its recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure, or distribution is prohibited unless otherwise consented to for coordination of services.
The Social Worker at Wood County Society is a mandated reporter for individuals who are a danger to themselves or others, and there is an identified instance of suspected abuse, neglect, and/or exploitation of children, animals, the elderly, and individuals with intellectual and developmental disabilities. If the person you are referring is experiencing a mental health crisis, please close this form immediately and dial 911.
If you wish to complete your referral anonymously, please type "N/A."

Date of Form

First and Last Name of person completing this form

First and Last Name of person being referred

If you know, please provide the information for the preferred method of contact of the person being referred.

Choose the category that best fits the reason for your referral Safety concernsNeed for servicesAdvocate supportOther

Choose the level of urgency and preferred contact time for your referral (if the individual is in crisis, please close this form and dial 911) Immediate (24 hours)Intermediate (72 hours)Not urgent (one week)

Please describe your relationship to the person you are referring (ex. parent, partner, family, friend, colleague, etc)

Please describe, in as much detail as possible, the person you are referring and the reason you decided to complete this referral

Do you want the social worker to disclose to this person that you are the one who completed the referral? YesNo

I have read and understand the instructions and disclaimers at the top of this form. I agree that the information in this referral form is true and accurate to the best of my knowledge. I agree to allow the Social Worker at Wood County Society to view this referral and initiate necessary services for the individual being referred. Yes