Chrysalis Referral Form

Chrysalis Referral Form

"Work is Recovery"
Note: This referral is intended to be completed in collaboration with the person interested in joining the Chrysalis Community. Their input, preferences, and agreement are central to the process. The individual’s signature will be included on this referral to confirm their participation. If the Legal Guardian is not present to sign, please proceed with participant signatures and we will follow up with guardians.
Referral Information
Legal Name*

First NameLast Name
Chosen Name (if different than legal name)
Pronouns
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Who does the alternative number belong to? (ex. parent, Service Facilitator, etc...)
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a Legal Guardian?

YesNo
Legal Guardian Name, if applicable*

First NameLast Name
Legal Guardian Phone*
Please enter a valid phone number.
Legal Guardian Email Address*
example@example.com

Mental Health Treatment Team Information

If you are not currently connected to a Mental Health Treatment Team, please respond with "n/a"
Case Manager or Service Facilitator Name*

First NameLast Name
Email*
example@example.com
Treatment Team Agency*
What funding source are you connected to?*

CCSCRSOther
Which type of Medicaid do you receive, if any?*
Dane County Client ID
MA #
ICD-10 Diagnosis Code

Authorization for Release of Confidential Information

Purpose of the ROI: a) To facilitate coordination of care, case management, and service delivery b) To support treatment planning and monitoring c) To address employment, legal, educational, or health-related concerns
I hereby authorize Chrysalis to obtain from and release to {treatmentTeam} the following information:
- Mental health treatment plans
- Mental health diagnoses and clinical notes
- Work-related information (including employment status, job performance, and vocational support)
- Educational records (including academic progress, IEPs, and attendance)
- Current and past medical and health records (including both physical and mental health information)
- Criminal background history
This information may be shared for the purpose of coordinating care, facilitating treatment planning, supporting vocational or educational goals, and ensuring appropriate services are provided. I understand that this authorization allows for two-way communication between Chrysalis and the agency listed above.

This ROI will expire 1 year from the date of electronic signature unless otherwise requested.
Printed Name of Participant or Legal Guardian*

First NameLast Name
Date*

MonthDayYear
Date
Signature of Participant or Legal Guardian*

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Which Chrysalis Program/s are interested in learning more about?

Vocational Peer Support: Vocational Peer Specialists provide individual support over a shared lived experience of mental health and/or substance use with peers who are working on their vocational goals.Clubhouse Work Ordered Day: A supportive community where members work together to run the Clubhouse, build relationships, and develop skills.IPS Supported Employment: A program that helps people find and keep competitive jobs in the community. *Eligibility for IPS Supported Employment is based on treatment team partnerships. Eligible participants must be connected to: SOAR, CIT, RISE, FLYY, Orchestra X, Gateway, CTA, or Keystone.
Please tell us about the goals you'd like to address in your above program selections.
Are there any provider preferences*, accessibility needs, or other accommodations that would help you feel comfortable and supported while participating in our services? (*a program leader will reach out to discuss the capacity to fulfill specific provider request)

Telehealth Informed Consent
I hereby consent to participate in telemental health services with Chrysalis as part of my psychosocial rehabilitation services. I understand that telehealth is the practice of delivering health care services via technology assisted media or other electronic means when two people are located in different locations.

I understand the following with respect to telehealth communication:

1. I understand that there are risks associated with telehealth, such as confidentiality breaches if someone should walk into the room or technical difficulties that may result in service interruptions. If we are unable to reconnect with video, we may resume our session with regular voice communication.

2. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

3. I understand that although my provider makes every effort to protect my privacy by using a secure server, they cannot guarantee the security of any information transmitted over the internet. By using telehealth services, I recognize that transmissions over the internet are at my own risk and that third parties may unlawfully intercept or access the transmissions.

4. I understand that there will be no recording of any of the online sessions. Information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

5. I understand that I have the right to withdraw consent at any time without affecting my right to future care or treatment.

I have read the information and understand the risks and benefits related to the use of telehealth services. I hereby give my consent to participate in the use of telehealth services.
Printed Name of Participant or Legal Guardian*
Date*

MonthDayYear
Date
Signature of Participant or Legal Guardian*

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Clubhouse Tour Request
Please only complete this step if you indicated the Clubhouse Work Ordered Day as a program you're interested in. If not, please select 'next' to submit your referral.

Click here to schedule your Clubhouse Tour!

Thank you! A member of our team will be in touch shortly to discuss your referral.
Should be Empty:

Chrysalis Referral Form

Referral Information

Mental Health Treatment Team Information

Authorization for Release of Confidential Information

Telehealth Informed Consent

Demographic Data

Clubhouse Tour Request