Access to Wellness Referral Form

Please complete 1 submission per Access to Wellness Award Request

The purpose of the Access to Wellness program is to leverage existing resources and partnerships to develop a coordinated response that is supportive of individuals who often present within multiple systems.

The overarching goal of the Access to Wellness program is to support community tenure, successful recovery, and positive long-term outcomes for individuals diagnosed with a severe mental illness.

Client Name

Date of Birth

mm/dd/yyyy

Primary Diagnosis

Client Adress

If the recipient is currently unhoused, check the homeless box below and this field will no longer be required.

Homeless

Client County

Required for funding.

Athens

Vinton

Hocking

Income Source

N/A

YES

Client Eligibility Criteria: Part 1

*Two inpatient psychiatric hospitalizations within the past 12 months

*Two Crisis Stabilization Unit (CSU) stays within the past 12 months

*One inpatient psychiatric hospitalization & one CSU stay within the

past 12 months

*Currently involved in an Outpatient Competency Restoration Program

*Currently incarcerated in jail and in need of supports upon release

Psychiatric Discharge Date: 1

mm/dd/yyyy

Psychiatric Discharge Date: 2

mm/dd/yyyy

Client Eligibility Criteria: Part 2

Please select the multiple systems that the client is currently involved with. (Two systems must be selected to meet eligibility requirements)

Clinician Contact Information & Agency

Please Include email address and phone number

Fiscal Agent

Please include email address and phone number

Treatment Plan

Provide details including total funding request. Please include services/ supports needed such as type of housing provided, recovery gap needs, treatment, emergency basic need items, transportation and psychiatric home health needs.

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