Agency Referral Form

Please complete the information below to be added to our referral list!  This list is utilized by Ohio CIP Facilitators to help link participants with additional community resources and assistance.

Agency Information

Name of Agency *

Agency Phone *

Agency Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

County or Counties Served *

Agency Website / URL *

Agency Point of Contact *

First

Last

Point of Contact Email *

Services Provided

Layout

What services does the agency provide? (select all that apply) *

• Case management
• Counseling
• Dental Care
• Education/GED Assistance
• Gambling Disorder Treatment
• Family Support Services
• Food Assistance
• Housing Assistance
• Mental Health Services
• Reentry Assistance
• Relapse/Recurrence Prevention (Support Groups)
• Routine Medical Care
• SUD/Addiction Treatment Services
• Transportation Assistance
• Veteran Assistance
• Vision Care

Agency – Please select all areas of counseling expertise

• Adult
• Faith-based
• Family
• LGBTQ+
• Marriage
• Trauma
• Youth
• Other

Please specify. *

Please select all applicable family services provided by the agency. *

• Daycare/childcare
• Family Programming
• Family Planning
• Other

Please specify. *

Please select all applicable reentry assistance provided by the agency. *

• Transition Services
• Career/employment assistance
• Case Management
• Benefit Assistance
• Other

Please specify. *

Please select all applicable treatment/recovery services provided by the agency.

• Co-ocurring Mental Health
• Detox
• Medically Assisted Treatment
• Outpatient Treatment
• Residential Treatment
• Sober living
• Wrap-around services
• Other

Please include the wrap-around services provided by the agency. *

Please specify. *

Please select all transportation services provided by the agency *

• Bus passes
• Gas cards
• Transportation to and from work or medical appointments
• Other

Please specify. *

Submit