Anazao Community Partners (ACP) Access Referral

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Please use the following form to make referrals to Anazao Community Partners.

ACP Access staff will review referrals and make follow-up contact to Clients and/or Guardians. This will include a brief screening to determine eligibility and appropriateness for services. Should Access staff have further questions after speaking with the Client and/or Guardian, they will reach out to Referral Sources.

Once clients are deemed eligible and intake paperwork has been completed, Clients will be scheduled with an ongoing provider.

Please insure you have informed the client (and guardian) of any referrals you are making into ACP services.

If you'd like to learn more about services please visit our website at www.anazaocommunitypartners.org

Collateral information can be sent to: fax@anazaocp.hush.com

Email *

Client First Name *

Client Last Name *

Grade/Age *

School District Attending *

Guardian Name (if applicable)

Guardian Relationship to Client (if applicable)

Parent

Grandparent

Foster Care, CSB Custody

Other:

Clear selection

Client/Guardian Phone Number (XXX-XXX-XXXX) *

Client/Guardian Email

Client/Guardian County of Residence *

Holmes

Wayne

Ashland

Medina

Summit

Stark

Other:

Presenting Concern(s) (Check all that apply) *

Post-Crisis, Post-Hospitalization or Post-Incarceration

Mental Health Needs (i.e. anxiety, depression)

Substance Use/Abuse

SCHOOLS ONLY: Substance-Related Disciplinary Referral

Significant Trauma, Loss or Grief

Court Involvement

Conflict Resolution, Social Skills or Emotions Management

Resource Deficiency (i.e. needs connection to social services or supports)

Lack of Focus, Motivation and/or Time Management

Challenges in family relationships, need support to family unit

Families Working Together referral

Other (please describe in next section)

Required

Please provide any additional information about reason for referral or presenting concerns here.

Individual is being referred by: *

Self

Child Protective Services (list agency in next section)

Probation (list county and department in next section)

Courts (list county and department in next section)

Medical provider (list details in next section)

School (list school in next section)

Other Partnering Agency (list agency and program in next section)

Other Therapy Provider (list provider name and agency in next section)

Jail/Prison (provide location and detail in next section)

Other (provide detail in next section)

Please provide specific detail about referral source: *

Referral Source Contact Information

Are you aware of insurance or other coverage for if there is a fee for services? *

Unaware of Client's Coverage

Medicaid

Commercial Insurance

Medicare

No Coverage

Required

INTERNAL ONLY: Client Date/Time Scheduled and Provider Initials (ex: 1/1 12:00 JS)

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