Members of conflict-affected populations can face a wide range of issues beyond those that agencies they are directly in contact with can address. Organizations can identify issues at individual or community level that are not directly covered through their own programmers or mandate. Staff, frontline workers and community members are sources of information on services available and can help persons of concern to access the services they need. A referral is the process of directing a potential member to another service provider because she/he requires help that is beyond the expertise or scope of work of the current service provider.

MEMBER INFORMATION
First Name	Last Name	Date of Birth	Social Security #
Place of Birth	Email	Age	Gender
			MaleFemale
Physical Home Address		PO Box Address
Phone #	Eye Color	Hair	Height
Weight	Pref Language	Last TB	Last Physical
	EnglishSpanishOther
Funding Sources	AHCCCS #	AHCCCS Plan Name	Eligibility Status
DDD	CMDP #	COT #	Category
			Choose an itemSerious Mental Illness (SMI)SMI-Special AssistanceGeneral Mental Health (GMH)Substance Abuse (SA)Child/Adolescent
Guardian Name		Guardian Email
Guardian Address		Guardian Phone
Current Meds	Allergies	Marks / Tattoos	Race
			Choose an itemAfrican AmericanAsianCaucasianNative AmericanHispanicOther
DIAGNOSIS
Code	Name / Description	Code	Name / Description
Presenting Problem:
Most Recent Evaluation:

POINT OF CHOICE BEHAVIORAL HEALTH INC - OUTPATIENT SERVICES
PROGRAMS	TYPE OF SERVICES	POINT OF CHOICE BEHAVIORAL HEALTH INC PROGRAMS AND SERVICES
Outpatient	ClinicalLife SkillsCourt Order Treatment	Rise Up ProgramVictory ProgramPeer SupportGroup TherapyDomestic ViolenceDUIFamily Support ServicesParentingMentoringDBT (Dialectical Behavior Therapy)CBT (Cognitive Behavioral Therapy)Counseling IndividualSubstance AbuseCounseling GroupCommunity SupportCase Management/Care CoordinationBehavior Coaching Individual & GroupRespite Individual & GroupPsychoeducation IndividualPsychoeducation GroupVocational Skills Training Individual & GroupAssessments & ScreeningSocial Determinants of HealthSkills Training and Development Groups/IndividualsWork Readiness & Workforce ProgramSupported HousingFamily TherapyRN SERVICESNEMT (Non-Emergency Medical Transport)

UPLOAD DOCUMENTS (Kindly upload necessary documents like BHSP,CompAssmt,ETC)

Guiding Principles for Inter-Agency Referrals

In order for a referral not to create harm to the individual/community in need of assistance, the referral needs to respect at all times the following principles:

1. Confidentiality: The principle of confidentiality requires all parties involved, volunteers, and community members to protect information disclosed or gathered in relation to any individual and to ensure that information is made accessible to a third party (i.e. service providers) only with the individual’s explicit permission.
2. Consent: Referrals should only take place once the individual has given their informed consent. The individual has the right to limit information s/he wishes to disclose and persons with whom information will be shared.
3. Respect the individual: Our partnership seeks to provide information about services available, in order for them to make a free and informed choice. Our agency commits to ensuring members are treated with dignity, decision-making capacities and preferences. You are not supposed to express your opinion, pass judgment or blame the individual.