Community/Agency Outreach
Please note that Outreach services are not a substitute for crisis response. All requests for service will be reviewed and an appointment will be scheduled at the earliest date available.
Name of agency making referral
Name of referring staff.
Contact information for staff. Email and direct phone number.
Name of individual being referred for services.
Age or DOB of individual being referred.
Address of individual.
Phone number and/or e-mail of individual.
Does the individual have any of the following criteria? (Check all that apply)
Severe and Persistent Mental Illness
Substance Use Disorder
Violent felonies
Felony drug sales
Sex Offender status
Services Needed:
Housing Services
Mental Health Treatment
Substance Abuse Treatment
Medication Management
Peer Services
Health Home Care Management
County Benefit application assistance (SNAP, TA, Medicaid, etc.)
Connection to Primary Care Doctor
Victim of Domestic Violence
Perpetrator of Domestic Violence
LOSS (Local Outreach to Suicide Survivors)
Veterans Services
Gender of individual
Male
Female
Transgender
None of the above
Important information for Outreach team to have
Has the individual agreed to this referral?
Yes
No
Submit
Should be Empty: