Referral Packet Request

A complete Referral Packet must contain all of the following items:

1. Referral Checklist & Questionnaire (links below)

2. Individual Service Plan (ISP) / Treatment Plan (for SMI clients). Needs to include the verbiage Peer Support (this will cover both individual and groups), Skills Training (this will cover both individual and groups), Transportation - Nonemergency (A0120 and S0215). Signed and dated by Member, Staff, and BHP (or include Affidavit)

3. Assessment - Must cover ISP dates of service. Signed and dated by Staff or include Affidavit.

4. Release of Information (Health Home to Hope Lives)

Who can submit a Referral?

• Members (self)

• Clinic Case Managers

• Hospital/Therapist Offices

• Other Peer & Family Organizations

• Hope Lives Employees

The Hope Lives Referral Forms can be found here:

• Phoenix

• Flagstaff

• Kingman

Please print out and fax completed referrals to 602-388-1567 or one of the following contacts below.

• Phoenix: referrals@vivehopelives.org

• Flagstaff: northreferrals@vivehopelives.org

• Kingman: mohavereferrals@vivehopelives.org

Hope Lives will notify the member and referring party (if different) when they are eligible to start attending.