Referrals Peer Support

Date

Are you in need of an interpreter?

If yes, which language?

Referral Source

Leave any comments or concerns for the referring person:

Email of referring person:

Contact number of person referring:

Status of Referred Individual

Consumer name:

First and Last Name

Consumer Contact Number- Please do not add dashes to the numbers. Add ONLY numbers. :)

Consumer date of birth:

Date

Consumer Social Security number:

Phone

Program Descriptions:

Recovery Community Organization provides day time support groups and Peer support. If an individual does not have transportation, Peer staff may be able to meet them where they are.

LifeLife Peer Respite is a 6 bed home, which if an individual meets criteria, they would have an opportunity for a very brief stay. Peer staff will be able to gain an understand a recovery plan to assist an individual towards living a full independent life.

PATH - Project Assistance to Tranition from Homelessness- The criteria:

Must be experiencing homelessness or at risk of homelessness

Must have a severe and persistent mental illness

May have a substance misuse, yet severe and persistent mental illness is the need

Must have sustainable income or meet criteria for SSI,SSDI, Outreach, Access, Recovery (SOAR)

SOAR is an evidenced based practice involving a condition severe enough to meet SSA crtiera of disability. Trained SOAR Peer staff will assist with the application process and follow through.

Referral to which Program

Why is this individual being referred to RiteLife Services, Inc.?

Education Group

Is there currently a Release of Information for RiteLife Services, Inc.?

YesNo

Referral Form