Behavioral Health Respite Referral Form
Referral Source Information
Name
*
Relationship to person:
*
Choose an item:
Brother
Father
Grandfather
Grandmother
Mother
Other
Sister
Step-mother
Step-father
Agency
Email
*
example@example.com
Title/Position
Has guardian consented to Respite Services:
*
Yes
No
Phone Number
*
Youth's Information
Youth's name
*
Preferred name
Date of birth
*
/
Month
/
Day
Year
Date
Address
*
Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip
Race/Ethnicity:
*
Please Select
African American
American Indian/Alaskan Native
Asian
Caucasian
Hawaiian or Other Pacific Islander
Hispanic
Other
Gender Identity:
*
Please Select
Female
Male
Other
Transgender
Preferred Pronouns:
*
Please Select
He/Him/His
She/Her/Hers
They/Them/Theirs
Other
Spirituality/Religion:
*
Please Select
Christian
Jewish
Muslim
Other
Protestant
Roman Catholic
Primary modes of communications:
*
Electronics
Gestures
Sign-language
Verbal
Visual
Written
School name
Medicaid Number 12 digits
Is the youth currently involved in OhioRISE?
*
Yes
NO
Has BH Respite been added to the youth's care plan?
*
Yes
No
Current Medications?
*
Yes
No
Current medications
Current Allergies?
*
Yes
No
Allergies
Current Medical Issues?
*
Yes
No
Current medical issues
Current diagnosis
*
Reason for Referral
*
Please check any of the following behavior challenges:
*
Difficulties Self Regulating
Eating Disorder
Eloping/running away/AWOL
Property Destruction
Physical Aggression
Self-Harm
Sexual Behavior
Verbal Aggression
Withdrawal
Suicidal ideation/attempts
Homicidal ideation/attempts
SUD Issues
Unable to self-protect
Issues at school
Issues with family members
Other
Comments on Behavioral issues:
*
Any special needs/accommodations to be aware of?
*
Been a victim of a crime?
*
Yes
No
Witnessed a crime?
*
Yes
No
Been in a serious accident?
*
Yes
No
Been in a natural disaster?
*
Yes
No
Has/had a serious illness?
*
Yes
No
Family members/significant people in life have had serious illness?
*
Yes
No
Sustained a serious injury?
*
Yes
No
Experienced the death of someone close?
*
Yes
No
Has experienced anything else they consider traumatic?
*
Yes
No
Describe
Special considerations due to trauma
*
Has the client been a victim of physical, sexual, or emotional abuse
*
Has the client been a victim of neglect or exploitation
*
Client Preferences
Clients likes/Dislikes
*
Clients hobbies/interests
*
Triggers to the client
*
Day's Available for Respite:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Hours available for Respite:
*
Morning (8am-12pm)
Midday (12pm - 4pm)
Evening (4pm - 8pm)
Guardian/Parent Information
Name
*
Relationship to Individual
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
example@example.com
Secondary Emergency Contact
Name
Relationship to Individual
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Email
example@example.com
Submit
Should be Empty: