Referral

Anyone can complete this form to add a referral for services at RFI.

NOTE: RFI does not have Licensed homes for minors at this time.

Referral Information

Member Name/Initials:
Member Age:
Location
Diagnoses:
List mental health diagnoses and medical conditions.
Service(s) Requested:
Service Needs/Hours:
How many hours/days of each service are being requested?
Funding Source:

Person Making Referral:

Does the member have behaviors?
If yes, please describe:
(i.e. Property Destruction, Self-injurious, Aggressive, Inappropriate touch, etc.)
Does the member require personal care?
If yes, please describe:
(i.e. Needs full support in restroom, verbal reminders, etc.)
Name of Person Making Referral:
Phone:
Contact Information:
Care Manager Name (if not listed above):
Upload any documents that could be helpful in evaluating the referral:
Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Non-Discrimination Statement

Reach for Independence, Inc. provides services and accepts referrals without regard to race, color, national origin, religion, sex, age, disability, genetic information, sexual orientation, gender identity, or any other characteristic protected by applicable federal or state law.

All referrals are reviewed based on service needs, program availability, and the ability to safely and appropriately support the individual.

 

Guardian Release of Information