OCAPICA Wellnessessity - Referral Form

Referral Form
Referring Person/Title:
Agency/Dept:
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Submission Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
You are completing this form as:
PARTICIPANT INFORMATION
Name
Gender
Sex
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
School (if applicable)
Ethnicity
Language
Do you have health insurance?
Insurance Name
Insurance Number
PARENT/CAREGIVER OR EMERGENCY CONTACT INFORMATION
Name
Relationship
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Language:
REASONS FOR REFERRAL
I am looking for (select all that apply)
Do any of these apply to you?
Do you need a bilingual worker?
If yes, specify language:
Do you need any other accommodations?
If yes, please specify:
Do OCAPICA staff need to talk with referring person prior to intake?
Has Participant been notified that an OCAPICA staff will contact them?
OK to leave voice message?
OK to leave text message?
Please write availability for introductory call appointment:
SERVICE AGREEMENT AND AUTHORIZATION TO RELEASE INFORMATION
If you are completing this form on behalf of a participant, please read the following and complete all fields below and indicate that verbal consent was obtained from the participant prior to submission:

The participant authorizes the release of information between {referringPersontitle} {agencydept} (referring agency) and OCAPICA for the period this service agreement remains in effect. This information will pertain to the reasons for referral and will be used for assessment and intake of the participant(s) to be served. This referral was explained to the participant in the participant's primary language.
Participant Verbal Consent Obtained (if applicable)
Participant Signature or Authorized Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring Person Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For Well(ness)essity Staff Only
Wellnessessity staff: please enter the internal reference to access page 2.
Non-staff: you can skip now.
Enter internal reference (if applicable):
Client is an Adult or a Child/Youth?
Adult (Age 21 or Older)
Which POF best fits client?
Homelessness: Adults Experiencing Homeless
Adults at Risk for Avoidable Hospital or ED Utilization
Adults with Serious Mental Healthand/or Substance Use Disorder (SUD) Needs
Adults living in the community who are at risk for LTC Institutionalization

Member is actively experiencing at least one complex social or environmental factor influencing their health (including, but not limited to: Needing assistance with activities of daily living, communication difficulties, access to food, access to stable housing, living alone, the need for conservatorship or guided decision-making, poor or inadequate caregiving which may appear as a lack of safety monitoring); AND
Pregnant and Postpartum Individuals at Risk for AdversePerinatal Outcomes
Child/Youth (Under 21)
Which POF best fits client?
Homeless Families or Unaccompanied Children/YouthExperiencing Homelessness
Children and Youth At Risk for Avoidable Hospital or ED Utilization
Children andYouth with Serious Mental Health and/or SUD Needs
Children/Youth Enrolled in California Children’s Services (CCS) or CCS WCM with Additional Needs Beyond the CCS Condition

Member is experiencing at least 1 complex social factor influencing their health. Examples include (but are not limited to) lack of access to food; lack of access to stable housing; difficulty accessing transportation; high measure (four or more) of ACEs screening; history of recent contacts with law enforcement; or crisis intervention services related to mental health, former foster youth, and/or substance use symptoms
Children/Youth Involved in Child Welfare
Should be Empty:

Referral Form

PARTICIPANT INFORMATION

PARENT/CAREGIVER OR EMERGENCY CONTACT INFORMATION

REASONS FOR REFERRAL

SERVICE AGREEMENT AND AUTHORIZATION TO RELEASE INFORMATION

For Well(ness)essity Staff Only

Adult (Age 21 or Older)

Child/Youth (Under 21)