Open Heart Leaders Referral Form

Open Heart Leaders Referral Form
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
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