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.
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.
Your relationship to person being referred*
Has parent/guardian consented to respite services?*

YesNo
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?*

YesNo
Has Behavior Health Respite been added to the youth's Care Plan?*

YesNo
Does the youth have a provider gender preference?*

FemaleMaleNo Preference
Is youth currently receiving Behavior Health Respite from another provider?*

YesNo
Will the youth continue to receive Behavior Health Respite with that provider?*

YesNo
Is the youth currently taking any medications?*

YesNo
List Current Medications*
Does the youth have any medical/allergic conditions*

YesNo
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*

Difficulties self-regulatingEating disorderEloping/Running away/AWOLProperty DestructionPhysical aggressionSelf-harmSexual acting outVerbal aggressionWithdrawnSuicidal ideation or attemptsHomicidal ideation or attemptsSUD issuesUnable to self-protectOther
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.
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