Fax Referral

Armed Services YMCA Family Outreach Fax Referral Form (858) 751-5769 Fax (858) 751-5755 Office Please complete and fax information requested below to the Armed Services YMCA.

All referrals will be followed up with a phone call by a Family

Outreach Social Worker to the person referred.

To ensure and protect client

confidentiality, information on the status of referrals or participation in our programs will not be provided unless authorized by the client.

Feel free to

contact us with any questions! Contact Information Client Name:

_______________________________Active Duty (Rank/Rate_______)

Dependent

Spouse Name:

______________________________Active Duty (Rank/Rate_______)

Dependent

Address:

___________________________________________________________________

Best Contact Number: (____)___________________________________________________ Referral Source Name:

___________________________________Position:

__________________________ Address:

_________________________________Phone:

(____)_______________________ Reason for Referral

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________ Authorization to Release Information I, ____________________________, hereby authorize the Armed Services YMCA (ASYMCA) to release and disclose information either verbally or in writing to the Referral Source above, only relating to the status of the referral (i.e., ability of the ASYMCA to make contact with the client) or client enrollment in an ASYMCA Program.

This release does not include any information

related to medical, psychological, social, psychiatric treatment and/or prognosis.