{"id":808,"date":"2024-11-09T01:15:02","date_gmt":"2024-11-09T01:15:02","guid":{"rendered":"https:\/\/empowercommunityinitiative.org\/?page_id=808"},"modified":"2024-11-10T22:04:10","modified_gmt":"2024-11-10T22:04:10","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/empowercommunityinitiative.org\/?page_id=808","title":{"rendered":"Referral Form"},"content":{"rendered":"<h2 style=\"text-align: center;\">Referral Form<\/h2>\n<p>&nbsp;<\/p>\n<div style=\"text-align: left; margin-left: 45px;\"><code>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f849-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"849\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F808#wpcf7-f849-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"849\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f849-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:849,&quot;conditions&quot;:[],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_uacf7_hidden_conditional_fields\" value=\"\" \/>\n<\/div>\n<div class=\"uacf7-form-849 uacf7_auto_cart_849\"><span class=\"wpcf7-form-control-wrap\" data-name=\"ParticipantFirstName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"fname\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"ParticipantFirstName\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ParticipantLastName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"lname\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"ParticipantLastName\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ParticipantPhone\"><input size=\"40\" maxlength=\"10\" minlength=\"7\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" autocomplete=\"tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"tel\" name=\"ParticipantPhone\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Birth\" value=\"\" type=\"date\" name=\"DOB\" \/><\/span>\n<label> Address: <\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"StreetNumber\"><input size=\"40\" maxlength=\"15\" minlength=\"3\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Street Number\" value=\"\" type=\"text\" name=\"StreetNumber\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"StreetName\"><input size=\"40\" maxlength=\"15\" minlength=\"3\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Street Name\" value=\"\" type=\"text\" name=\"StreetName\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"City\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"City\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"State\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"State\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required Country\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Country\" value=\"\" type=\"text\" name=\"Country\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Gender\"><span class=\"wpcf7-form-control wpcf7-radio Gender\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"Gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"Gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ReferralContact\"><input size=\"40\" maxlength=\"10\" minlength=\"3\" class=\"wpcf7-form-control wpcf7-text\" autocomplete=\"name\" aria-invalid=\"false\" placeholder=\"Referral Contact\" value=\"\" type=\"text\" name=\"ReferralContact\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ReferralPhone\"><input size=\"40\" maxlength=\"15\" minlength=\"3\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Referral Phone\" value=\"\" type=\"tel\" name=\"ReferralPhone\" \/><\/span>\n<label>Date of Comprehensive Assessment : <\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ComprehensiveDate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date ComprehensiveDate\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"ComprehensiveDate\" \/><\/span>\n<label>If participant has a PMAP\/Insurance, please enter All information below<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Provider\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text Provider\" aria-invalid=\"false\" placeholder=\"Provider\" value=\"\" type=\"text\" name=\"Provider\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"GroupNumber\"><input size=\"40\" maxlength=\"15\" minlength=\"3\" class=\"wpcf7-form-control wpcf7-text GroupNumber\" aria-invalid=\"false\" placeholder=\"Group Number\" value=\"\" type=\"text\" name=\"GroupNumber\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PolicySubscriber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text PolicySubscriber\" aria-invalid=\"false\" placeholder=\"Policy\/Subscriber Number\" value=\"\" type=\"text\" name=\"PolicySubscriber\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MedicaidID_PMI\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text MedicaidID_PMI\" aria-invalid=\"false\" placeholder=\"Medicaid ID\/PMI\" value=\"\" type=\"text\" name=\"MedicaidID_PMI\" \/><\/span>\n<label>If participant has only MA (Medical Assistance), please provide ALL the information below.<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MedicaidID_PMI\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text MedicaidID_PMI\" aria-invalid=\"false\" placeholder=\"Medicaid ID\/PMI\" value=\"\" type=\"text\" name=\"MedicaidID_PMI\" \/><\/span>\n<label style=\"padding: 10px;\">Referral must include a comprehensive assessment that\nindicates at least a risk rating of 1 in Dimension 4,5 or 6 \nand must include a recommendation for Peer services<\/label>\n\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PrimarySUD_diagnosis\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text PrimarySUD_diagnosis\" aria-invalid=\"false\" placeholder=\"Primary SUD diagnosis\" value=\"\" type=\"text\" name=\"PrimarySUD_diagnosis\" \/><\/span>\n\n<label>Service start date (enter the date the referral is sent - mm\/dd\/yyyy)<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Service_StartDate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date Service_StartDate\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"Service_StartDate\" \/><\/span>\n\n<label> Service Provided <\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ProvededServices\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"ProvededServices[]\" value=\"Education\" \/><span class=\"wpcf7-list-item-label\">Education<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ProvededServices[]\" value=\"Attending recovery and other support groups\" \/><span class=\"wpcf7-list-item-label\">Attending recovery and other support groups<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ProvededServices[]\" value=\"Accompany the client to appointments for recovery support\" \/><span class=\"wpcf7-list-item-label\">Accompany the client to appointments for recovery support<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ProvededServices[]\" value=\"Assistance in accessing resources\" \/><span class=\"wpcf7-list-item-label\">Assistance in accessing resources<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ProvededServices[]\" value=\"Recovery support to assist a person in the transition from treatment\" \/><span class=\"wpcf7-list-item-label\">Recovery support to assist a person in the transition from treatment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ProvededServices[]\" value=\"Advocacy\" \/><span class=\"wpcf7-list-item-label\">Advocacy<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"ProvededServices[]\" value=\"Mentoring\" \/><span class=\"wpcf7-list-item-label\">Mentoring<\/span><\/label><\/span><\/span><\/span>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/><\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"225\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/code><\/div>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Referral Form &nbsp; &nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_uag_custom_page_level_css":"","footnotes":""},"class_list":["post-808","page","type-page","status-publish","hentry"],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false},"uagb_author_info":{"display_name":"abdulw","author_link":"https:\/\/empowercommunityinitiative.org\/?author=1"},"uagb_comment_info":0,"uagb_excerpt":"Referral Form &nbsp; 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