OhioRISE Referral Form

OhioRISE Referral Form

Please fill out the required details to refer a child for OhioRISE services. If you have any questions, you can contact Christine Johnson at 5135570093 or christine@honorworth.com.
Name of youth being referred*

First NameLast Name
Language Spoken at Home*
Youth Date of Birth*

MonthDayYear
Date
Medicaid ID (Optional)
Youth Physical Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Youth's Current Placement Type*
Race/Ethnicity*
Gender Identity*
Preferred Pronouns*
Spirituality/Religion*
ElectronicsGesturesSign-languageVerbalVisualWritten
School name*
If the youth does not attend school, please specify here
YesNo
YesNo
Special considerations due to trauma*
YesNo
YesNo
County*
Name of person making referral*

First NameLast Name
Title of person making referral*
Contact number of person making referral*
Please enter a valid phone number.Format: (000) 000-0000.
Email of person making referral*
example@example.com
Date of Referral*

MonthDayYear
Date
Name of Guardian*

First NameLast Name
Relationship of Legal Guardian to Youth*
Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Email Address
example@example.com
Diagnoses *
Are there any needs or expectations that have already been discussed with the guardian in regards to service needs?*
How soon are you looking to start services?*
YesNo
Difficulty self-regulating emotionsSevere mood swingsAnxiety symptomsDepressive symptoms / withdrawalTrauma-related behaviors (PTSD symptoms)Dissociation / “zoning out” episodesN/A
Self-harm (cutting, burning, etc.)Suicidal ideation / attemptsHomicidal ideation / threatsUnable to self-protect / vulnerability to exploitationRisky sexual behavior / sexual exploitation concernsRunning away / elopement / AWOLN/A
Physical aggressionVerbal aggressionProperty destructionDefiance / oppositional behaviorImpulsivity / poor judgmentFire-setting behaviorsN/A
Issues at school (attendance, suspension, expulsion)Academic difficulties / learning challengesBullying (victim or perpetrator)Difficulty following rules or routinesN/A
Conflict with family membersDifficulty with peer relationshipsSocial isolation / withdrawalCaregiver conflict or placement instabilityN/A
Substance use disorder (SUD) concernsAlcohol useTobacco / vaping useMedication misuseEating disorder / disordered eatingN/A
Attention / hyperactivity concerns (ADHD symptoms)Cognitive or developmental delaysPoor executive functioning (planning, organization)Sensory processing difficultiesN/A
Sexualized behaviorsLegal involvement / juvenile justice involvementGang involvement / peer criminal influenceN/A
Should be Empty: