OhioRISE Referral Form
Are you referring for yourself or on behalf of someone else?
Referral Contact Name
Referral Contact Email
Doctor's office, county department, etc.
Youth Date of Birth
Youth's Legal Guardian Name
Youth's Legal Guardian Phone Number
Youth's Legal Guardian Contact Email
Relationship of Legal Guardian to Youth
Biological, kinship, agency, etc.
Street Address 2
Youth County of Residence
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?
Is the youth being referred for a WAIVER CANS assessment through the OhioRISE Waiver Program?
How did you hear about NYAP?
Participant of other NYAP program(s)
Pamphlet or Flyer
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.
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