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Refer Someone for Services

This form is designed to collect essential information for a referral with Imagine the Possibilities. Please provide accurate and detailed responses to ensure a smooth and efficient referral process. Your input will help us identify requirements, and strategize the referral process effectively. One of our Referral Team members will reach out to you if required.  Please only submit one individual per form. 
 

Have questions? Contact referral@imagineia.org

Referral Information

Date Completed
Month
Day
Year
Is this an URGENT Referral?
Legal Gender
Gender Identity
Ethnicity (Select All That Apply)
Primary Language Preference
Do you know the individual's home address?
Yes
Homeless
Unsure of full address

Service Needs and Diagnoses

Primary Diagnoses or Disability
Level of Care Needed
Service Type
Does this individual require a handicap accessible home?
Yes
No
Does this individual have any environmental adaptations needed?
Yes
No
Does this individual have an Emotional Support Animal?
Yes
No
Can this individual live in a co-ed home?
Yes
No
Service Area (Location) Desired

Individual History

Please check all that apply. (List is not all inclusive)
Does the individual have any specialized medical needs such as routine treatments or injections?
Yes
No
Does this individual have specialized dietary or eating needs?
Yes
No
Is this individual incarcerated?
Yes
No
Is this Individual currently on or ever has been registered as a sex offender in the past?
Yes
No
Has this individual been hospitalized in the prior 12 months?
Yes
No
History of Suicide Attempts
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Physical Aggression
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Property Damage
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Elopement
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Self-Injurious Behavior
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Sexually Aggressive Behavior
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Non-Aggressive but Inappropriate Sexual Behavior
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Fire Setting
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of PICA/Swallowing
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Substance Abuse
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
History of Criminal Behavior
None
History of (12 months or longer ago)
Recent (Within the last 12 months)
Access to Weapons (including firearms)
Yes
No

Enter if the individual has orders in place for Payee services, Court Orders, Guardian, etc.

Please enter SSI, SSDI, etc.

Referral Source Information

Is the Case Manager different from the Referral Source?
Yes
No
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