Referral Form - Respite for Kids

Please note: If the youth is not affiliated with Unison Health, we will need a release of information and the youth's care plan reflecting the need for respite services in order to integrate them into our system.

Youth's Full Name

Youth's DOB

Youth's Gender

Youth's Medicaid ID Number

Youth's Social Security Number

Youth's Address

Youth's City

Youth's State

Youth's Zip Code

Guardian's Full Name

Guardian's Phone Number

Guardian's Email Address

Care Coordinator's Full Name

Care Coordinator's Phone Number

Care Coordinator's Email Address

Do you have a specific respite provider in mind to provide services?

Yes No

If Yes, please list the provider's name and email below.

Please have the parent/guardian complete the Release of Information form to reflect the Care Coordinator's agency in section 2, "Who can the PHI be given to?". Please ensure all sections are completed, regardless of "required" status. Please note that Respite4Kids administrators cannot begin the process of reviewing or obtaining information until this form is complete.

Youth's OhioRISE Care Plan

Youth's Release of Information Form from Other Agency

By submitting this referral, I agree that the care plan will document the need for respite services for the duraction of the youth's OhioRISE enrollment. If there is a change, in the youth's OhioRISE status, or respite services are no longer needed, I will reach out to the respite contact for this program and notify them immediately.