Transition to Independence Program (TIP) Referral Form:COMPLETE REFERRAL FORM BELOW and send supporting materials/documentation to: TIP@hopelinkbh.org.Please enable JavaScript in your browser to complete this form.YOUNG PERSON'S DEMOGRAPHIC INFORMATION - Full Name: *FirstMiddleLastPhone (cell): *Phone (other):Street Address: *Street address, including Apt/Unit # if applicableCity, State *Zip Code *Email Address:Current School Attending (if applicable):Current School District (if applicable):THIS QUESTION TO BE ANSWERED BY THE YOUNG PERSON/ADULT BEING REFERRED. Why do you want to participate in TIP? *DSM DIAGNOSES - Primary Mental Health Diagnosis Code and Description: *Additional Mental Health Diagnoses: *Primary Medical Diagnoses (if applicable):REFERRAL SOURCE INFORMATION: Self-Referral (Young Adult/Adult) *YesNoNatural Support (Family or Friend) *YesNoIf yes to natural support, please include Referring Person's Contact InfoFormal Support (professional) *YesNoIf yes to formal support, please include Referring Person's Name, Affiliation, and Contact InfoSYSTEM INVOLVEMENT: Mental Health Outpatient Involvement (CSB Mental Health/Private Agency) *YesNoIf yes to previous question, include Agency Name and Provider Contact Info:Probation Involvement: *YesNoIf yes to previous question, include Jurisdiction and Probation Officer's Contact Info:Department of Family Services Involvement: *YesNoIf yes to previous question, include Agency Name and Provider Contact Info:Intellectual Disabilities Involvement (CSB Intellectual Disability/Developmental Disability Agencies): *YesNoIf yes to previous question, include Agency Name and Provider Contact Info:Drug & Alcohol Treatment (Any): *YesNoIf yes to previous question, include Agency Name and Provider Contact Info:Office of Vocational Rehabilitation (Dept. of Aging and Rehabilitative Services (DARS), Other Employment Services): *YesNoIf yes to previous question, include Agency Name and Provider Contact Info:Other:YesNoIf yes to previous question, include Agency Name and Provider Contact Info:DISCLAIMER AND SIGNATURE: *I certify that my answers are true and complete to the best of my knowledgeI understand that submitting this TIP referral does not guarantee enrollment into the TIP Program, and a staff member will contact me at the earliest convenience.I understand my agreement to these questions and typing my name below is equivalent to a written signature.Include name below as indication of SIGNATURE (self): *Today's Date: *Include name below as indication of REFERRING PERSON'S SIGNATURE (if applicable):Today's Date:Submit to PRS Send supporting materials/documentation to: TIP@hopelinkbh.org.
