OhioRISE Referral Form
Are you submitting a referral for yourself or on behalf of someone else?
*
Myself/My Child
Someone Else
If you are submitting a referral on behalf of someone else, is their legal guardian aware the referral is being made?
Yes
No
N/A
Referral Contact Name
First Name
Last Name
Referral Contact Email
example@example.com
Referral Agency
Doctor's office, county department, etc.
Youth's Name
*
First Name
Last Name
Youth's Date of Birth
*
-
Month
-
Day
Year
Date
Youth's Legal Guardian's Name
*
First Name
Last Name
Youth's Legal Guardian's Phone Number
*
-
Area Code
Phone Number
Youth's Legal Guardian's Contact Email
example@example.com
Relationship of Legal Guardian to Youth
*
Biological, kinship, agency, etc.
Youth's Address
*
Street Address
Street Address 2
City
State
Zip Code
Youth's County of Residence
*
Allen
Auglaize
Champaigne
Clark
Darke
Greene
Hardin
Logan
Madison
Miami
Shelby
Other
If you marked "other", what is the youth's county of residence?
Is the youth being referred for a CANS assessment due to a Qualified Residential Treatment Program (QRTP) placement?
*
Yes
No
Is the youth being referred for a WAIVER CANS assessment through the OhioRISE Waiver Program?
*
Yes
No
How did you hear about NYAP?
Social Media
Google Search
Website
Participant of other NYAP program(s)
Friend Referral
Pamphlet or Flyer
Professional Referral
Other
Please verify that you are human
*
Click Submit Below to Complete
Once completed, your referral will be processed within 24 business hours. You will be contacted by a National Youth Advocate Program (NYAP) team member. Thank you so much for your inquiry.
Submit
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