Care Coordination Referral Form

Care Coordination Referral Form

The South Dakota Resource Hotline is offering Substance Use Care Coordination to assist individuals by advocating, connecting and supporting their recovery process. If an individual or yourself may benefit from Care Coordination, please complete this form and the Substance Use Care Coordinator will follow up.
Are you or the person you're here for a resident of South Dakota? (This question is for the individual seeking services)*

YesNo
This program is for South Dakota residents. If you are outside of South Dakota, get connected with local services in your area by dialing 211 or visit 211.org.
We are here to help! Can you tell us who you are filling this form out for?*
Name of Individual Making Referral*

First NameLast Name
Phone Number of Individual Making Referral*
Please enter a valid phone number.Format: (000) 000-0000.
Is the individual aware of this referral? *
If individual is not aware of this referral, we will follow up with the person making the referral.
Your relationship to this person
Friend, spouse, partner, counselor, ect.
Name of individual seeking services*

First NameLast Name
Address (for individual seeking services)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip code (for individual seeking services)*
Phone Number for individual seeking services*
Format: (000) 000-0000.
What is the best time to contact the individual seeking services?*

9 AM - 1 PM1 PM - 5 PMAfter 5 PM
May we leave a voicemail?*
May we text this number?
Email
example@example.com
Provide any information about your situation that we should know when we call.*
To help us better understand who we are reaching out to, please provide us with some details.

(These should be for the individual seeking help)
What is your date of birth? *

MonthDayYear
If declined, put 12-12-1212
What is your Gender? *
What is your Race?*
What is your Ethnicity?*

Hispanic or LatinoNot Hispanic or LatinoDeclined
Are you a Veteran?*

YesNo
How did your hear about our Care Coordination services?*

988211AveraProblem Solving CourtsKeystone Treatment CenterOther
I acknowledge that the information I have provided will be used by the Substance Use Care Coordinator for the purpose of coordinating referrals and services.
Yes, I acknowledge.*
Administrative Notes: *
Should be Empty: