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), Pre Job Development (H2027), 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.