REFERRAL FORM
1950 W. Heatherbrae Dr. Suite 2 Phoenix, AZ 85015 602.246.7607 Referral Fax 602-424-6241
Email: Referrals@azchr.org	website: www.azchr.org
Date of Referral 	

Name of Person being referred	 Date of Birth; 	/	/	

AHCCCS ID: 	Phone # (where the individual can be reached):	

Address: 	City:	 Zip Code: 	
□ Male □ Female □ Transgender □ Pregnant □ Postpartum
□	SMI / RBHA
□	GMH/SA
□	ALTCS
□	ALTCS Personal Medicine Referral
Interpreting services needed?□ Yes  □ No
Health Plan coverages: Name of Health Plan or Benefit:	
Required Documents for Referrals from Provider Agencies / Clinics / Health Plans
□	Current Assessment (diagnostic evaluation) *Must include BHP Signature*

□Current Individual Service Plan (ISP) *Must Include (both) BHP and member signatures*

□Note: ISP must list the services you are referring the member for **see Notice Below **

□Authorization to Release Information

** Notice: At a minimum, the initial ISP must identify and need for Peer Support Services. After an initial intake is completed, CHR and the member may request that additional services be added to the / their ISP. This is based on member choice and the program schedule which provides a variety of groups and programming that are billed using a variety of billing codes that need to be listed on the ISP.
Peer Delivered Services offered at CHR and that would be listed on an ISP and that allow for member choice:

1.	Peer Support – to identify needs, overcome barriers and cope with stressors, in order to promote long term sustainable recovery
2.	Skills Development - to improve the ability to live and participate in the community and function independently, e.g. developing a social support network, self-care, communication, budgeting and community resources etc.
3.	Psychoeducational/ Pre-Job Training & Development – Ongoing support for employment or volunteer opportunities
4.	Behavioral Health Prevention Education - to increase the person's knowledge of illness or health condition
5.	Non-Emergency Transportation - Services to engage in skill development activities or recovery activities.

Self-Referrals or Non- Provider Referrals: For individuals not referred by a Provider Agency or who do not have a current assessment or ISP, CHR will arrange for the individual to receive an assessment and have an individual service plan completed by a qualified BHP.

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Referring Provider/ Site/Clin	Phone: 	
Name and Email address of assigned Case Manager:	_ Email: 	
Please send Referral and Required Documents to
Referrals@azchr.org or fax to 602-424-6241

Note: For Peer Employment Training Referrals there is an additional form that must be completed and sent with this referral packet, form can be found at www.azchr.org Programs, Peer Employment Training