Members of conflict-affected populations can face a wide range of issues beyond those that agencies they are directly in contact with can address. Organizations can identify issues at individual or community level that are not directly covered through their own programmers or mandate. Staff, frontline workers and community members are sources of information on services available and can help persons of concern to access the services they need. A referral is the process of directing a potential member to another service provider because she/he requires help that is beyond the expertise or scope of work of the current service provider.

MEMBER INFORMATION
First Name	Last Name	Date of Birth	Social Security #
Place of Birth	Email	Age	Gender
			MaleFemale
Physical Home Address		PO Box Address
Phone #	Eye Color	Hair	Height
Weight	Pref Language	Last TB	Last Physical
	EnglishSpanishOther
Funding Sources	AHCCCS #	AHCCCS Plan Name	Eligibility Status
Insurance provider(primary)	Member ID	Group ID	Coverage Start Date
Select OptionAetnaAIHP (American Indian Health Plan)Arizona Complete HealthArizona Foundation BannerBanner|AetnaBlue Cross Blue Shield of ArizonaCare1st Health PlanCignaCigna HealthCare of ArizonaFirst HealthHealth Choice ArizonaHealth NetHumanaMercy Care PlanMolina Healthcare IncMultiPlanN/ANO INSURANCEOscar HealthTRICAREUnited HealthcareUnitedHealthcare of Arizona
Insurance provider(secondary)	Member ID	Group ID	Coverage Start Date
Select OptionAetnaAIHP (American Indian Health Plan)Arizona Complete HealthArizona Foundation BannerBanner|AetnaBlue Cross Blue Shield of ArizonaCare1st Health PlanCignaCigna HealthCare of ArizonaFirst HealthHealth Choice ArizonaHealth NetHumanaMercy Care PlanMolina Healthcare IncMultiPlanN/ANO INSURANCEOscar HealthTRICAREUnited HealthcareUnitedHealthcare of Arizona
DDD	CMDP #	COT #	Category
			Choose an itemSerious Mental Illness (SMI)SMI-Special AssistanceGeneral Mental Health (GMH)Substance Abuse (SA)Child/Adolescent
Guardian Name		Guardian Email
Guardian Address		Guardian Phone
Current Meds	Allergies	Marks / Tattoos	Race
			Choose an itemAfrican AmericanAsianCaucasianNative AmericanHispanicOther
SDOH(Social Determinants of Health)		Type of substances
Access to Quality HealthcareEducation and Childhood DevelopmentFood InsecurityHomelessness and Housing InstabilityJustice or Legal InvolvementSocial Isolation and Social SupportEmployment InstabilityNeed for Transportation AssistanceNeed for Utility AssistanceInterpersonal SafetyEnvironmental SafetyAccess to Outdoor Spaces and Parks		Alcohol (Beer, Wine, Spirits)Marijuana (Marijuana, Cannabis, THC)Opioids (Heroin, Fentanyl, Prescription Pain Killers)Nicotine (Nicotine, Cigarettes, Vapes)Stimulants (Cocaine, Methamphetamine)Sedatives (Benzodiazepines, GHB)Synthetics (Synthetic Cannabinoids [K2/Spice]. Synthetics Cathinones [Bath Salts], Ketamine GHB)Hallucinogens (MDMA, Ecstasy/Molly, LSD, PCP [Phencyclidine], Peyote [Mescaline], Psilocybin)
Individualized Education Program - IEP(Optional)		IEP details and description(Optional)
DIAGNOSIS
Code	Name / Description	Code	Name / Description
Presenting Problem:
Most Recent Evaluation:

CHOICE INTEGRATED HEALTHCARE INC - OUTPATIENT SERVICES
PROGRAMS	TYPE OF SERVICES	CHOICE INTEGRATED HEALTHCARE INC PROGRAMS AND SERVICES
Outpatient	Court Order TreatmentLife SkillsClinical	Individual CounselingGroup CounselingPeer SupportCase ManagementGroup Skills Development & TrainingIndividual Skills Development & TrainingVictory ProgramRise-Up ProgramRespite CareMentoringMedical ServicesFamily SupportRN Services

UPLOAD DOCUMENTS (Kindly upload necessary documents like BHSP,CompAssmt,ETC) NB: To upload multiple files - Select or drag multiple files at the same time.

Guiding Principles for Inter-Agency Referrals

In order for a referral not to create harm to the individual/community in need of assistance, the referral needs to respect at all times the following principles:

1. Confidentiality: The principle of confidentiality requires all parties involved, volunteers, and community members to protect information disclosed or gathered in relation to any individual and to ensure that information is made accessible to a third party (i.e. service providers) only with the individual’s explicit permission.
2. Consent: Referrals should only take place once the individual has given their informed consent. The individual has the right to limit information s/he wishes to disclose and persons with whom information will be shared.
3. Respect the individual: Our partnership seeks to provide information about services available, in order for them to make a free and informed choice. Our agency commits to ensuring members are treated with dignity, decision-making capacities and preferences. You are not supposed to express your opinion, pass judgment or blame the individual.