Michigan Private Agency Client Referral 

Client Information
Client Contact Information

XXX - XX -

Agency & Case Information

Caseworker Information

Michigan DHS My Agency Other
DHS Case Monitor
Please note, a copy of this referral will be sent to the DHS monitor for approval before processing is complete.

Agency Billing Information 
Please note, this selection means that your agency will be responsible for payment.

Other Information 
Please describe your circumstances and a representative will be in touch with you shortly. 

Secondary Caseworker

Screen Information

What is Random Ongoing Testing? 

When you choose Random Ongoing Testing, you are selecting for your client to participate in the call in program and have a random schedule generated. You must select the amount of screens you would like per a duration (7 day period, 30 day period, or year period) and beginning/end screening dates. 

What is One Time Screening ? 

When you select ‘One Time Screening’ you are choosing for your client to have 1 test at a date you decide. You must enter a beginning screening date. 

What is Non Call in Ongoing Testing?

When you select ‘Non Call In Ongoing Testing’ you are choosing for your client to have ongoing testing on dates of your deciding with no Call In feature. You must enter a beginning screening date. 

 screens per 

Need assistance with this form?