RSI Crisis Response Referral
This referral is necessary to initiate Safehouse and/or Crisis Staffing Services with RSI. Our team will be in touch quickly upon receipt.
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Email *
Person's Name *
Anticipated Dates of Stay/Staff Need *
What events lead to requesting RSI Crisis Support? *
Address *
Guest's Phone Number *
Guest's Email Address *
Alternate Phone Number
Primary Caregiver Contact Number *
Primary Caregiver/Home Manager Name *
Primary Caregiver/Home Manager Phone/Email *
Parent/Guardian Name, Phone, Email, Address *
Case Manager/IRIS Consultant Name, Phone, Email *
Behavioral Consultant Name, Phone, Email *
Primary Doctor Name, Location, Phone, Next Appointment *
Psychiatrist Name, Location, Phone, Next Appointment *
Therapist Name, Location, Phone, Next  Appointment *
Additional Specialist Name, Location, Phone, Next Appointment *
Name I Prefer *
DoB, Age, Gender, Pronouns *
Details and Events Leading to RSI Involvement *
Likes *
Dislikes *
Suggested Approaches to Support *
Home Setup for Personal and Staff Safety *
Do I use remote support  for any hours of my day? *
If Yes, Which hours am I supported remotely? *
Weekly Scheduled Activities *
Important Details for Support in the Community *
Important Details for Support in the Community *
Medical Diagnoses and Conditions *
Scheduled Medications and Med Times *
PRN Medications and Uses *
Personal Care Support Needs *
Special Dietary Needs *
Preferred Foods *
Disliked Foods *
Phone Use Restrictions *
Phone Use Restriction Details *
Visitors Allowed, and Support Needs During Visits *
Television Limits or Restrictions *
Household Cleaning Expectations/Limitations *
Spending Money Available and Limitations *
Other Support Details
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