Rising Phoenix Genesis New Referral Submission

Rising Phoenix Genesis New Referral Submission

Submit a new referral for Rising Phoenix Genesis. Please provide accurate details for both the referrer and the referred individual. Please feel free to contact Lydia Newlin with any questions or concerns at lnewlin@risingphoenixwi.com or 651-303-1493
Status of Referral
Admin Communication Notes
Provider Assigned
Date Assigned

MonthDayYear
Date
Date of Referral

MonthDayYear
Date
Funding Program (Please enter the program which applies to this referral.)
CLTS Service Requested (Please provide a short narrative that describes the CLTS service needs for the potential recipient.)
CCS Service Requested (Please enter the CCS service desired. If there is more than one service desired, please select all that apply.)
Safe Landing Service Requested
Referral Method (If you are a Service Facilitator or Service Coordinator and you are completing this form, please select "Direct Entry by SF / SC". If you reached out via email to one of the listed email addresses or directly to a service provider, please select that option.)
County (Please select from the options or describe the desired service)

Other
Service Facilitator Name (Please select your name if it is listed, if it is not, please select "NOT LISTED" and fill in your name in the next question.)
Service Facilitator Name (If not in the dropdown list above.)
Email Address for the Service Facilitator/Coordinator
example@example.com
Phone Number for the Service Facilitator/Coordinator
Please enter a valid phone number.Format: (000) 000-0000.
Potential Recipient's Initials (Please provide the potential recipient's initials to assist in tracking the request.)
Potential Recipient's Age
Potential Recipient's Gender
Potential Recipient's Location (Please enter the recipient's hometown or area for assistance in matching with an appropriate provider.)
Preferred Language
Preference for Gender of Provider (Please enter the preferred gender for the provider's gender or select "Either" if there is no preference.)
Willing to consider an alternative gender
General Provider Request (If there are specific concerns that must be adhered to in matching a recipient to a provider, please select it here. You can select more than one. If none, please select "N/A". You can type in your own response if needed.)

Other
Requesting a Specific Provider (If you are requesting a specific provider, please select the name of that provider. If there are no specific requests, please select "any.")
Frequency and Length of Visit Requested (Please enter the frequency and length of visits requested. For example, are you looking for a provider once a week for a 2-hour session? Does the client need a provider three days a week for one-hour visits?)
Potential Recipient is UNABLE to meet during the following days and times. (If known)
Diagnosis (Please select from the listed diagnoses or type in any additional ones not listed. You may select more than one.)
Recipient Background (Please enter any pertinent background information that would be helpful in matching the recipient with a service provider. This could be family functioning, development, educational history, etc.)
Recipient Interests (Please enter any interests that the recipient has that may assist with matching them to the service provider that would be the best fit for them. Please type in any that aren't listed, if applicable. If typing in something, you need to hit "Enter" after typing it in order for the information to remain in the box.)
Recipient Goals (If known):
Provider Safety Concerns (Are there any safety concerns the provider should be aware of? If no, please note: N/A. For example: Elopement, Unsafe Public Behavior, Unsafe Behavior in Vehicles, Physical Violence, Sexual Boundary Issues, Suicidality, Environmental/family Safety Concerns, History of False Allegations, Major Triggers, Severe Allergies, Domestic Abuse, Substance Use.)
Additional Information or Comments if applicable
Should be Empty: