ACI Behavioral Health Respite Service Referral

Behavioral Health Respite Service Referral
Referral Source Information

Complete this section so we may contact you.
Your Name

First NameLast Name
Agency
Title / Position
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Email
example@example.com
Your Supervisor's Name

First NameLast Name
Your Supervisors Email Address
example@example.com
Your Supervisor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your relationship to person being referred
Has parent/guardian consented to respite services?
Youth's Information
Youth's Name

First NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Race/Ethnicity
Gender Identity
Medicaid Number
12 - Digits
Is youth currently enrolled in OhioRISE?
Has Behavior Health Respite been added to the youth's Care Plan?
Does the youth have a provider gender preference?
Is youth currently receiving Behavior Health Respite from another provider?
Will the youth continue to receive Behavior Health Respite with that provider?
Is the youth currently taking any medications?
List Current Medications
Does the youth have any medical/allergic conditions
List Current medical issues/allergies
Current Diagnosis with respective codes.
Current Diagnostic Information
Diagnosis 1: Diagnosis* . Associated code: Diagnostic Code*
Diagnosis 2: Diagnosis . Associated code: Diagnostic Code
Diagnosis 3: Diagnosis . Associated code: Diagnostic Code
Diagnosis 4: Diagnosis . Associated code: Diagnostic Code
Describe the child/family's situation that makes respite services a requirement
Please list youth's strengths, interests, and preferred activities:
Please check any of the following behavior challenges which currently apply

Other
Comment on behavioral challenges
Any special needs/accommodations to be aware of
Parent or Legal Guardian Information

If Applicable
Name

First NameLast Name
Person's relationship to youth and youth's legal status
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address if different than youth's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Behavioral Health Respite Service Referral

Referral Source Information

Youth's Information

Current Diagnostic Information

Parent or Legal Guardian Information