OCAPICA Wellnessessity - Referral Form

OCAPICA Well(ness)essity Program Referral Form
Referring Person/Title:
Agency/Dept:
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Date

MonthDayYear
Date
PARTICIPANT INFORMATION
Name
Gender
Sex
Address
Phone Number*
Please enter a valid phone number.
DOB

MonthDayYear
Date
Age*
School (if applicable)
Ethnicity*
Language*
PARENT/CAREGIVER OR EMERGENCY CONTACT INFORMATION
Name
Relationship
Address
Phone Number
Please enter a valid phone number.
Language:
REASON FOR REFERRAL
I am looking for (select all that apply):

Peer Support ServicesResource NavigationPEARLS ServicesCounseling
Have you ever experienced or witnessed discrimination based on race, ethnicity, gender, or sexuality, which you feel has affected your wellbeing?

YesNo
Do you need a bilingual worker?

YesNo
If yes, specify language:
Do you need any other accommodations?

YesNo
If yes, please specify:
Do you have any insurance?

YesNo
If yes, please specify:
Do OCAPICA staff need to talk with referring person prior to intake?

YesNo
Has Participant been notified that an OCAPICA staff will contact them?

YesNo
OK to leave voice message?*

YesNo
OK to leave text message?*

YesNo
Please write availability for intake appointment:
SERVICE AGREEMENT AND AUTHORIZATION TO RELEASE INFORMATION
The referring party has explained to me the purpose for this referral and I agree to have a copy of this referral faxed or to take a copy of the referral to OCAPICA. I agreee to attend any scheduled appointments with the Program.

I authorize the release of information between {agencydept} {referringPersontitle} (referring agency) and OCAPICA for the period this service agreement remains in effect. This information will pertain to the reasons for referral and will be used for assessment and intake of the participant(s) to be served. This referral was explained to me in my primary language.
Participant Signature

Clear
Date

MonthDayYear
Date
Referring Person Signature

Clear
Date

MonthDayYear
Date
How did you hear about us?

InstagramFacebookNewsletterOCAPICA WebsiteRecommended by someone (coworker, friend, family, etc...)Other
Should be Empty:

OCAPICA Well(ness)essity Program Referral Form

PARTICIPANT INFORMATION

PARENT/CAREGIVER OR EMERGENCY CONTACT INFORMATION

REASON FOR REFERRAL

SERVICE AGREEMENT AND AUTHORIZATION TO RELEASE INFORMATION