Agency Referral to CHiP

Agency Referral to CHiP

Welcome! Please complete this secure referral form to connect your client with CHiP. This form is mobile-friendly and designed for your convenience. Do not include sensitive client information in email correspondence.
Community agencies, churches, counselors, nonprofit organizations, and other service providers may use this form to refer an individual or family to Catalysts Helping Increase Potential (CHiP). Submitting a referral does not guarantee services. CHiP will review the information and follow up as appropriate.
THIS FORM IS NOT FOR EMERGENCIES. If someone is in immediate danger or experiencing a medical or behavioral-health emergency, call 911.
Section 1: Referring Agency Information
Agency Name
Referring Staff Name
Referring Staff Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Staff Email
example@example.com
Referring Staff Job Title
Preferred Response Method
May CHiP contact the referring organization for additional information?
Section 2: Person Being Referred
Client's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Email Address
example@example.com
Current Address or General Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is the person currently experiencing homelessness?
Preferred method of contact
Best Time to Contact
Preferred Language
Does the person need an interpreter?
Accessibility or Accommodation Needs
Section 3: Assistance Requested
What assistance is being requested?

Other
Briefly describe the person’s current situation and the assistance being requested.
Include only information reasonably necessary for CHiP to evaluate the referral. Do not include Social Security numbers, bank or financial-account information, copies of medical records, or detailed diagnoses.
Has this person received assistance from CHiP before?
Other organizations currently assisting this person
Section 4: Referral Urgency
Is this referral time-sensitive?
Please explain the deadline or time-sensitive circumstances
Section 5: Client Knowledge and Authorization
Has the person authorized your organization to share the information included in this referral with CHiP?
“Does the person being referred know that this referral is being submitted to CHiP?”
Permission is required before submitting this referral.
Please obtain the individual’s knowledge and permission before submitting this referral. If you believe an exception applies, contact CHiP directly at 520-371-0004.
Section 6: Additional Information
Additional information CHiP should know
Please provide only information necessary to evaluate or coordinate the referral. Do not include Social Security numbers, bank information, medical records, or other unnecessary sensitive information.
Section 7: Referrer Certification
I confirm that the person being referred has authorized the referring organization to share the information provided in this form with Catalysts Helping Increase Potential (CHiP) for the purpose of evaluating and coordinating requested services. I understand that submitting this referral does not guarantee services or assistance.
Please review the information before submitting. Only include information reasonably necessary for CHiP to evaluate and coordinate the referral.
Referring Staff Electronic Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Agency Referral to CHiP

Section 1: Referring Agency Information

Section 2: Person Being Referred

Section 3: Assistance Requested

Section 4: Referral Urgency

Section 5: Client Knowledge and Authorization

Section 6: Additional Information

Section 7: Referrer Certification