Note: The form below cannot be used for a DHS referral related to a substance use assessment. For this contract (TANF or Child Welfare), we will need a copy of the Referral for Substance Abuse Assessment Form 04MP033E and a copy of the Consent for Release of Confidential Information Form 04MP001E. Both of these will need to be emailed to tanfcwreferrals@glmhc.net.

BE ADVISED: This form is monitored 8am to 5pm, Monday through Friday. Responses are provided the next business day. If you are experiencing a crisis, please call our 24-hour Crisis Line at 1-800-722-3611.

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