Referral to TA-RPG (Sam)

Referral Information
Self-referralCase Manager / Care CoordinatorMental Health ProviderCommunity AgencyOther
Referral Source Information
Referrer Name & Role
Agency/Organization
Email
example@example.com

YesUnsureNo
A self-pay option is available for individuals without care coverage. Payment type does not affect group experience or eligibility.
Medicaid / Managed Care (OHP)Other insurance (Private/Commercial)Not sure

Location & Availability

This group meets in-person at our Beaverton, OR office. Tele-health is not available at this time.

ADDRESS:	9725 SW Beaverton-Hillsdale Hwy., Suite 230
	Beaverton, OR 97005
DAY:	Thursday
TIME:	10:30 AM - 12:30 PM
START DATE:	To Be Determined

This day/time generally works for meI may have scheduling challengesThis day/time does not work for meThis location does not work for me
Is there anything else you would like us to know about you as we consider next steps?
What Will Happen Next?

After reviewing this form, a member of our team will reach out to:
- Answer any questions you may have
- Clarify process and expectations
- Schedule a formal pre-group screening with a clinician, if appropriate
DISCLOSURE

This is not a crisis service and does not replace individual therapy or emergency mental health care, and is not a recreational program. Final eligibility is determined during a clinical screening.
Should be Empty:

Rows	Yes	Unsure	No
I am open to participating in a small group setting (4-5 people)
I am willing to attend a weekly group for 10 weeks
I understand the group uses structured role-playing activities as a therapeutic tool
I am open to learning more about this format

Participant Information