Oaklawn Open Access Referral Form

Please note this HIPAA compliant form allows you to share information with us about the person you are referring to Oaklawn. It is a one-way communication tool.

We will use this information to inform our assessment and treatment if the client comes to us for services.

We will not reach out to clients to ask them to come in for an assessment, please share our Open Access Clinic Information with them. If you would like rack cards or fliers about Open Access for your organization, please fill out this form, https://hipaa.jotform.com/221033888759063, or email info@oaklawn.org

Please review our Services page https://oaklawn.org/our-services/ to ensure the service you’re referring to is one we offer. If you have questions about our services, please contact our Access Center at access.team@oaklawn.org

Your Name

First NameLast Name

Agency

County

ElkhartSt. JosephOther

If other, please specify here

Referral Source Preferred Contact Person

First NameLast Name

Referral Source Preferred Phone Number

Please enter a valid phone number.

Referral Source Preferred Fax Number

Please enter a valid fax number.

Referral Source Email (must include if you want a confirmation email)

example@example.com

Name

First NameLast Name

Date of Birth

Date

*If client is under 18 please enter guardian information

First NameLast Name

Relationship to client

Has client been made aware of this referral?

YesNo

I am sending this referral because of the following concerns (check all that apply)

Substance useMental health symptomsRisky behavior

Reason for referral additional details (please provide details such as most recent drug screen results, suspension/expulsion status from school, etc.)

Referral Source Goal for Intervention/Treatment

Is client currently receiving treatment at another facility?

YesNo

Name of facility (if known)

Current diagnoses (if known)

Current treatment (if known)

Please attach any relevant documents (including drug screenresults, risk assessments)

Oaklawn Open Access Referral Form

Referral Source

Client Information

If yes, please answer questions below