Referral Form
Thank you for taking the first step in the referral process! OhioRISE is a new specialized Ohio Medicaid managed care program for children and youth with complex behavioral health and multisystem needs. The JCESC OhioeRISE program is a proud partner with Ohio Medicaid in serving the following counties in Ohio: Belmont, Carroll, Columbiana, Harrison, Jefferson, Monroe, Stark, and Tuscarawas.
We will need some information to get started!
Please do not delay the referral process because you are not able to provide all of the information. Fill out as much as you can.
Name of Person Making This Referral
*
First Name
Last Name
Referral Contact Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Contact Email Address
example@example.com
Referral Agency: (If you are not representing an agency, please type in your relationship; for example; mother, father, aunt, teacher, etc.)
OhioRISE is a Medicaid funded program. Is the Youth you are referring Medicaid eligible?
*
Yes
No
I don't know
Name of Youth Being Referred
*
First Name
Last Name
Youth Date of Birth Date
*
-
Month
-
Day
Year
Date
Youth Email Address
example@example.com
Youth Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Youth Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County the Youth Currently Resides In:
Please Select
Belmont
Carroll
Columbiana
Harrison
Jefferson
Monroe
Stark
Tuscarawas
Other
Youth Gender
Please Select
Male
Female
Prefer Not to Answer
Youth SSN#
Youth Medicaid #
Is this a CPS or Juvenile Court Referral?
*
Please Select
Yes
No
If you answered YES to this question, please answer the following 2 questions.
If you answered 'Yes' to the previous question, is this a QRTP referral?
Please Select
Yes
No
Who is the worker/supervisor of this youth?
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Please provide additional information in the box below that you feel is important regarding this referral. (optional)
File Upload (optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How did you hear about the JCESC OhioRISE Program?
Friend Referral
Brochure/Flyer
Professional Referral
Social Media
Website
Other
Save
Submit
Should be Empty: