YARP MDT

Greater Columbia Behavioral Health BH-ASO Youth Access and Resource Program (YARP) Referral Form

If you or someone you know is experiencing a behavioral health crisis or emergency please contact Crisis Response at 509-792-1747 or 988. For medical emergencies or police response, please call 911
Referent Name

First NameLast Name
Form Email
example@example.com
Referent Email
example@example.com
Referent Phone Number
Format: 000-000-0000.
Best time to reach Referent
Todays Date

MonthDayYearHourMinutesAM/PM Option
Referent Relationship to youth

Other
Release of Information (ROI) Completed?
>>ROI MUST be signed by youth if 13 years or older or LEGAL guardian if youth is age 12 or younger.<<
If no, reason for no ROI
Name of Youth

First NameLast Name
Date of Birth

MonthDayYear
Age
Youth Address

Street Address

Street Address Line 2

City

Zip Code
City
Zip Code
State
Alternate Address
Format: Street, City, State, Zip
Have you notified the legal guardian of the referral?
Guardian Name

First NameLast Name
Guardian Phone

Area CodePhone Number
Guardian Email
example@example.com
Race/Ethnicity
Gender/Preferred Pronouns

Other
Tribal Affiliation
Tribe Name
Tribe Name
Preferred Language

Other
Interpreter Needed?
County of Residence

Other
Primary Care Physician
Insurance Provider

Other
Medicaid Provider
Behavioral Health Provider:
Behavioral Health Provider Name
Strengths/Interests such as sports, music, school clubs, religious activities, video games, reading
School/Education Program

Other
Name of School
Is Youth Currently at an Emergency Department?
Date Admitted

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Hospital
Brief history of the youth:

Other
Exposure to Substances in Utero?
Presenting symptoms

Other
Age of Symptom Onset
Most Urgent Need or Concern

Other
Additional information for most urgent need or concern
Medical Concerns
If Yes, list medical concerns
Substance Use Disorder:
If YES, describe Substance Use Disorder:
Cannabis

Other
Hallucinogens

Other
Inhalants

Other
Opioids

Other
Sedatives

Other
Stimulants

Other
Other Substances

Other
Desired outcomes of referral
Developmental Disabilities Administration involvement:
Juvenile Justice Center involvement:
Child Protective Services (CPS) involvement:
Department of Children, Youth & Families (DCYF) involvement
Natural support systems to be included in MDT such as: neighbors, extended family, religious organization or pastor, etc.
Other useful information
Send MDT Copy to Referent
Should be Empty:

Greater Columbia Behavioral Health BH-ASO Youth Access and Resource Program (YARP) Referral Form