Rapid Response Team Referral Form
Please fill out the following form to refer someone to RRT.
Full Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Other
Referring Person
*
First Name
Last Name
Reason For Referral
*
Non-fatal overdose / naloxone administration
Child welfare–related substance use concern
DUI / justice-involved substance use
Emergency department / EMS referral
Post-release from jail or prison
Other (brief description): ____________________
Safety and urgency
*
Immediate safety concerns known?
☐ Yes
☐ No
Preferred response timeframe:
☐ Within 24 hours
☐ Within 48–72 hours
Consent Status
*
Individual has not yet provided consent for information sharing beyond this referral
Individual has provided verbal permission to be contacted by RRT
Submit
Should be Empty: