Co-Responder Referral Form
This form is for ongoing case management referrals. If this is an active crisis during co-responder working hours, please also contact your Co-Responder Clinician for immediate support. Otherwise, this referral will be followed up on within one business day.
Your first name
Your last name
Is this referral for yourself or someone else?
Myself
Someone Else
Referral source
*
Federal Heights Police Officer
Brighton Police Officer
Other Jurisdiction Police Officer
Reaching HOPE Team
Other Service Provider
Friend
Relative
Other Personal Connection
Your agency (Other Service Provider)
Date of Encounter
-
Month
-
Day
Year
Date
Time of Encounter
Hour Minutes
AM
PM
AM/PM Option
Officer's first name (if any)
Officer's last name (if any)
Do you want a copy of the narrative section of this referral emailed to you?
Yes
No
Please provide your email for follow-up. This is only required if you want a copy of this referral emailed to you.
Please provide your phone for follow-up. This is optional.
Please enter a valid phone number.
Format: (000) 000-0000.
Please provide your phone for follow up and collaboration (phone or email is fine)
Information about person being referred
First name of person being referred
Last name of person being referred
Date of birth of person being referred
-
Month
-
Day
Year
Did the person being referred give permission for CRP to call them by phone?
Yes
No
Did not ask
Phone number of person being referred
Please enter a valid phone number.
Format: (000) 000-0000.
Did the person being referred give permission for CRP to contact them by email?
Yes
No
Did not ask
Email of person being referred
example@example.com
Is individual a minor?
No
Yes, legal guardian is aware of this referral and can be contacted
Yes, legal guardian is aware of this referral and CANNOT be contacted
Yes, other situation
Do you have the name of a caregiver or guardian?
Caregiver
Legal Guardian
No information
First Name of Caregiver/Guardian
Last Name of Caregiver/Guardian
Phone Number of Caregiver/Guardian
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Caregiver/Guardian
example@example.com
Preferred Language
English
Spanish
Other
Additional languages spoken
English
Spanish
Other languages spoken (if not above)
Living Situation of Person Being Referred
Live alone
Live with family / roommates
Unhoused - living in a car
Unhoused - living on the street
Other
At risk of homelessness?
Yes
No
Unknown
Address of person being referred
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address / Location of person being referred
Current location of person being referred
*
Federal Heights
Brighton
Street address where this person lives
City where this person lives
Aurora
Arvada
Bennett
Brighton
Commerce City
Federal Heights
Lochbuie
Northglenn
Thornton
Westminster
Other
State where this person lives
Colorado
Other
Postal Code for where this person lives
Gender
Female
Male
Transgender Male to Female
Transgender Female to Male
Non-binary / Gender fluid
Undisclosed
Other
Race and/or ethnicity (select all that are appropriate)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Other Race or Ethnicity (if it doesn't appear above)
Immigration status
US Citizen
Non US Citizen, with documentation
Non US Citizen, without documentation
Other
Any comments or concerns regarding the above contact information?
What resources might be beneficial for person being referred
Food
Housing
Medical services
Mental health services
Psychiatric (medication) services
Substance use / detox
Transportation
Legal support
Other Resources (if they don't appear above)
Reasons for referral
Mental Health concerns
Substance use concerns
Needs resources
Case report number (if applicable)
Call For Service number (if there is no Call For Service Number, enter 000)
*
Please provide any additional information that could be helpful in understanding the situation or needs of the individual, including the reason for the referral. This is the information that will be emailed to you if you opted to have a copy sent to you.
HH Client ID
Submit
Should be Empty: