Behavioral Health Respite Service Referral
Referral Source Information
Complete this section so we may contact you.
Your Name
*
First Name
Last Name
Agency
*
Title / Position
*
Phone Number
*
Please enter a valid phone number.
Your Email
*
example@example.com
Your Supervisor's Name
First Name
Last 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?
*
Yes
No
Youth's Information
Youth's Name
*
First Name
Last Name
Preferred Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
County
Race/Ethnicity
*
Gender Identity
*
Medicaid Number
*
12 - Digits
Is youth currently enrolled in OhioRISE?
*
Yes
No
Has Behavior Health Respite been added to the youth's Care Plan?
*
Yes
No
Is youth currently receiving Behavior Health Respite from another provider?
*
Yes
No
Will the youth continue to receive Behavior Health Respite with that provider?
*
Yes
No
Is the youth currently taking any medications?
*
Yes
No
List Current Medications
*
Does the youth have any medical/allergic conditions
*
Yes
No
List Current medical issues/allergies
*
Current Diagnosis
*
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-regulating
Eating disorder
Eloping/Running away/AWOL
Property Destruction
Physical aggression
Self-harm
Sexual acting out
Verbal aggression
Withdrawn
Suicidal ideation or attempts
Homicidal ideation or attempts
SUD issues
Unable to self-protect
Other
Comment on behavioral challenges
Any special needs/accommodations to be aware of
Parent or Legal Guardian Information
If Applicable
Name
*
First Name
Last 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
City
State / Province
Postal / Zip Code
Submit Your Referral
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