referral logo

CHOICE INTEGRATED HEALTHCARE INC

3350 N Arizona Ave., Suite #2, Chandler, AZ 85225
Phone: 480-656-5374       Fax: 480-546-4536
Email: admin@choiceihc.org       Website: choiceihc.org

SELF-REFERRAL / GUARDIAN REFERRAL FORM

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
Physical Home Address PO Box Address
Phone # Eye Color Hair Height
Weight Pref Language Last TB Last Physical
Funding Sources AHCCCS # AHCCCS Plan Name Eligibility Status
Insurance provider(primary) Member ID Group ID Coverage Start Date
Insurance provider(secondary) Member ID Group ID Coverage Start Date
DDD CMDP # COT # Category
Guardian Name
Guardian Email
Guardian Address
Guardian Phone
Current Meds Allergies Marks / Tattoos Race
SDOH(Social Determinants of Health) Type of substances
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
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.

Title Name Signature Signed Date
CLIENT SIGNATURE
LEGAL GUARDIAN SIGNATURE