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Referral Form – SIM Taskforce
1.
This form is to be completed by agencies receiving Recovery Support Funds under the BJA COSSUP initiative. It is designed to capture required reportable items in accordance with the COSSUP PMT tool. It collects required referral data and includes enhancements to support tracking, reporting, and evaluation.
Referral Overview
2.
Participant consented to follow-up contact:
Yes
No
3.
Participant client name:
4.
Participant client phone:
5.
Participant client address:
6.
Date of Referral
7.
Name of Referring Agency
8.
Staff Member Submitting Referral and email:
9.
Participants age range:
Under 18
18-24
25-34
35-44
45-54
55-64
65+
10.
Participants gender identity:
Female
Male
Non-binary
Prefer not to say
11.
Participants race/ethnicity (Select all that apply):
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Native Hawaiian or other Pacific Islander
White
Other
Prefer not to say
12.
Recovery Support Services Need:
13.
Select all recovery support services referred for this individual:
Peer support or recovery coaching
Family counseling
Food and nutrition assistance
Housing support services
Employment assistance
Case management
Faith-based support
Vocational training
Education (e.g., GED support)
Family reunification services
Transportation assistance
Assistance with benefits applications
Tribal/Cultural healing
Other (please specify)