Early Identification and Referral Form

EARLY IDENTIFICATION AND REFERRAL FORM Thank you for filling out this form. It will help track the number of referrals made by prevention providers as well as to find out if those referred are able to access treatment. Those referred are still qualified to receive prevention services.

Date: Name of person who completed this form:

Name of your agency/organization:______

About the person you identified/or referred:

Gender: Male Female Community in which referral took place

Is this person Hispanic or Latino? Yes No

Which racial groups describe this person?  African American Where was this person referred or for what was the person referred?  Asian  Hospital/emergency room/mobile crisis  Pacific Islander  School counselor  Native American  Mental health assessment / treatment  White  Substance use assessment / treatment  Mixed  Informed of crisis hotline  Other (Please specify: ______)  Talk with teacher, family member, etc.  Tutoring / academic counseling Age Category:  Physical health referral  0-4  Basic needs (food, shelter, clothing)  5-11  RBHA Customer Service  12-14  Medical Provider  15-17  Prevention Event  18-20 Other -please describe or use the back of the form to explain:  21-24 ______ 25-44 1 month follow up to referral. Which of the following best  45-54 describes the person’s situation as it relates to your referral?  55-64  No action taken following the referral  65+  Made an appointment, but person did not attend the appointment  No answer  Attempted to make an appointment, but person was denied services  Attempted to make an appointment, but person was wait listed for at Date of referral: _____Month ____Year least 1 month st Does this person have AHCCCS? ______No Yes  Made appointment and person received 1 service within 1 month ______Don’t know  Person received emergency services  Kept appointment, staff conducted assessment but person did not Was this referral related to substance abuse? return for services.  Yes  Other:______ No

Other comments?

Please track for one month.