(back page) Two-Way Referral Form Objective : Set-up a r'eferral system that facilitates ~ccess to services and information by client/ family and agencies. Instructions: 1. The personnel of the referring agency (e. g. barangay station; R. H. U. ) fills up the first half of the form providing pertinent data as indicated (i. e. case summary and reason for referral or services requested. 2. The client/family brings the referral form to the agency where referral Is made to avall of the services needed. 3. The personnel ofthe agency to which referrallsmadefills up the second half of the form, specifying the services renderetf/findfngs and recommendations, and sends back the form to the referring agency thmugh the cllent/family. 4. The client/family brings back to the referring agency (e. g., barangay station; R,. H. U. ) the duly accomplished second half of the form for decision, action or Information. The form Is flied with the client's record. 89 