Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Social Services Referral Form Template

Streamline Connections with Our Social Work Referral Template

Navigating social services can be overwhelming, especially for clients who need the right help quickly. This Social Services Referral Form Template is designed for social workers and organizations aiming to connect individuals to appropriate resources efficiently. With a clear structure, you'll benefit from faster referrals, improved communication among service providers, and a better overall client experience, all while ensuring compliance with accessibility standards. Start streamlining your referral process with this live template today.

Use this Template (FREE) Live Preview
Are you the client?
Yes
No
Referrer full name (if not the client)
Relationship to client or organization name
Referrer contact (phone or email)
Do you have the client's consent to share information for this referral?
Yes
No
How urgent is the need?
Immediate (within 24 hours)
Urgent (2-3 days)
Soon (within 1-2 weeks)
Routine (within 30 days)
Not sure
Client full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Preferred language
Interpreter needed
Yes
No
City or ZIP/Postal code
Client phone number
Client email address
Preferred contact method
Phone call
Text/SMS
Email
Voicemail only
Through referring organization
Best time to contact
Morning (8am-12pm)
Afternoon (12pm-5pm)
Evening (5pm-8pm)
Anytime
Weekends
Services requested (check all that apply)
Please Specify:
Current health coverage
Medicaid
Medicare
Private insurance
VA coverage
Uninsured
Not sure
Prefer not to say
Transportation access to attend appointments
Yes
Sometimes
No
Prefer not to say
Additional information that may help with this referral
Accessibility or accommodation needs
Wheelchair access
ASL interpretation
Language interpreter
Visual accommodation (large print, Braille)
Cognitive support or plain language
Home visit preferred
Remote/virtual appointments
None
Is anyone in immediate danger right now?
Yes
No
Do you have a safe place to stay tonight?
Yes
No
Signature
Date
I certify the information provided is accurate and authorize sharing it with relevant providers for service coordination.
Yes
No
{"name":"Are you the client?", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Are you the client?, Referrer full name (if not the client), Relationship to client or organization name","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a social services referral form template for FormCreatorAI article

When to use this form

Use this form when you need to connect a client to community resources quickly and capture the facts once. It fits schools, clinics, shelters, and libraries when a teacher, nurse, or advocate identifies needs like housing, food, elder care, or counseling. It also supports interagency handoffs, so your team can triage, prioritize, and track outcomes. For workplace or school incidents that require added support, pair it with an Office referral form. For seniors leaving the hospital or living alone, route follow-up using a Home care referral form. If your program accepts clients directly, offer a Self referral form so people can request help on their own.

Must Ask Social Services Referral Questions

  1. What is the client's immediate need and level of urgency?

    This helps you route the case to crisis, priority, or routine queues and set response times. Clear urgency signals reduce back-and-forth and prevent delays in care.

  2. What services has the client used recently, and what were the outcomes?

    This prevents duplicate referrals and avoids repeating services that did not work. If you also accept general requests, direct those to a Referral form to streamline intake.

  3. Are there any safety risks or safeguarding concerns we should know about?

    Documenting risks such as self-harm, abuse, or homelessness ensures staff take proper precautions. It also guides escalation to the right specialists or emergency contacts.

  4. What eligibility factors apply (location, insurance, benefits, language)?

    Eligibility details help you match the client to programs they can actually access. It reduces failed handoffs and speeds approvals.

  5. Do we have consent to share this information with the receiving agency?

    Explicit consent supports legal and ethical compliance and builds trust with the client. It also allows faster information sharing so services can start sooner.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel