Wraparound Services

Date of Referral:

Referring Organization Name:

Name and Contact Information of Employee you are Working with at Referring Agency:

First

Last

Employee's Title:

Employee's Phone Number:

Employee's Email:

Do you have a signed Release of Information on file to share with COTS?

Client's Name:

First

Middle

Last

Client's Primary Language

Client's Phone Number:

City in which Client Resides:

Client's Insurance:

Client's Medi-Cal Number:

the Notes Employee's

Client's Date of Birth:

If your client needs Medical Respite (Recuperative Care) please complete the Recuperative Care referral form here instead of this referral form.

Services Recommended for Client:

Housing Location Services (Housing Navigation): Support for persons experiencing homelessness to find housing and potientially receive assistance with a housing deposit.
Housing Retention Services (Housing Tenancy and Sustaining Services): Support for individuals or households who are at at risk of losing their housing due to challenges with lease compliance, paying rent or other related issues.
Medical Respite (Recuperative Care): Temporary bed, meals, and ongoing health condition monitoring and care coordination for individuals experiencing homelessness after exiting hospitalization.
Shelter, Meals, and Case Management for Individuals Exiting Institutions (Short Term Post Hospitalization Housing): Temporary bed, meals and care coordination for clients who are experiencing homelessness after exiting hospitalization, rehabilitation, inpatient psychiatric and substance use treatment centers, nursing facilities, or incarceration.
Healthcare Coordination* (Enhanced Care Management:) Wraparound case management with a focus on health care navigation and care coordination for clients who are members of one of the 4 Populations Of Focus we serve.

If Healthcare Coordination* was selected, select the applicable population group for your client

Youth experiencing homelessness: Individuals under 21 years of age who are unhoused or losing housing in the next 30 days; is inadequately housed (ex: couch surfing, living in motel, rv, campground, shelter, abandoned space).
Adult experiencing homelessness: Individuals 22 years of age or older with one or more chronic conditions that would benefit from care coordination.
Adults with high utilization of emergency departments or crisis units- 5 or more visits in 6 months.
Adults with serious mental health and/or substance use disorders.

Notes from Referring Angency: