The Val Ogden Center Is a Program Offering People Who Live with Mental Illness the Opportunity

Val Ogden Center Referral Form Thank you for your interest in the Val Ogden Center (VOC), a program of Consumer Voices Are Born (CVAB). We offer people diagnosed with mental illness the opportunity to become involved in a community of peers who believe in mental health recovery. We are a respectful community focused on empowering people in mental health recovery by supporting them in setting and achieving employment and education goals. The VOC Participants are given the opportunity to develop and use their talents and skills in an environment similar to a typical workplace. Attendance and participation is completely voluntary.

We request that VOC participants:  Have an employment or education goal that they will pursue through participation at the Center  Identify as being in mental health recovery  Be at least 18 years of age  Respect our clean and sober workplace policy  Have a desire to be an active participant in a supportive, safe and vital community

To foster a strong partnership in supporting a Participant in his or her recovery process, we would like a professional mental health service provider who is familiar with the person complete the following questions:

POTENTIAL PARTICIPANT’S INFORMATION First Name Last Name

Mailing Address

City State Zip Code

Primary Phone Number Secondary Phone Number

MENTAL HEALTH INFORMATION Mental Health Diagnosis YES NO

How can the VOC support this individual in his or her recovery?

What clinical information should the VOC be aware of in order to provide the best possible services?

SIGNATURE

Val Ogden Center 10201 NE Fourth Plain Rd. Vancouver, WA 98662 Phone: 360-253-4036 Fax: 360-253-9794 Val Ogden Center Referral Form Potential Participant Signature Date

Clinician’s Name (Please Print)

Clinician Contact Phone Clinician Email

Referring Agency

Val Ogden Center 10201 NE Fourth Plain Rd. Vancouver, WA 98662 Phone: 360-253-4036 Fax: 360-253-9794