Open Heart Leaders Referral Form

Open Heart Leaders Referral Form

To ensure a smooth handoff when sending clients to OHL, please also complete our Client Intake Form. This collects basic information to get participants started in the program and must be completed before any services at OHL can begin.
Referral Party's Information
Are you a current community partner of OHL?*

YesNoUnsure
Referral Party's Name*
Referral Party's Number*
Referral Party's Email*
Referral Party's Company or Organization Name*
Client Information
Referred Client's Information*
Parent or Guardian Information (If the referred client is under 18)
Name of Probation officer/CWS worker (Optional)
What is the reason for the referral? *
Please use this space to type the current situation of the client and why they are being referred.
What is the Client's Background? *
Please use this space to tell us a little more about the client (i.e. short narrative of their life story)
Assessment *
Please use this space to inform us of any current or suggested assessments on the client
Recommendation (What Programs/Services are you Referring the Client to?)*
Please use this space to inform us of any special recommendations or request you have for this client.
Client Scheduling
When will the Client be Available to Start?*

ImmediatelyOther
Is this Court Mandated?*

YesNo
Has the referred client filled out OHL's Client Intake Form?*

YesNo
You will be re-directed to the Required Intake form once this is complete. Thank you for your support.
Recommended Frequency*

WeeklyBi-WeeklyMonthlyOther
Client Information Continued
Current Diagnosis Information (Optional)
Please identify all risk factors or special concerns/issues (Domestic Violence including: hx, violence, runaway, safety, and SI)*
Approved Number of Sessions
Authorization Start Date

MonthDayYear
Date
Compensation
Method of Compensation*

My Organization or Company will be invoiced for this participantParticipant is responsible for their own feesMy Organization or Company has an MOU or Contract with OHLOther
Should be Empty:

Open Heart Leaders Referral Form

Referral Party's Information

Client Information

Client Scheduling

Client Information Continued

Compensation