Referral Tracking and Closed-Loop Verification Form

Logs outgoing and incoming referrals with follow-up contact and outcome to confirm the client connected to the receiving service. Used by case managers to demonstrate warm handoffs.

Referral Record

• Referral ID / Case Number
  Internal case or referral identifier. Do not enter the client's full name or SSN in this field.
• Referral Direction
  Is this an outgoing referral you are sending, or an incoming referral received from a partner?
• Date Referral Was Made
  The date the referral was initiated or received.
• Referral Method
  How was the referral communicated?
• If 'Other', describe the referral method
• Referring Staff Member Name
• Referring Staff Role / Title

Client Consent and PII Handling

• Client Identifier (Non-PII)
  Use an anonymized or coded identifier (e.g., initials + last 4 of case number). Do NOT enter full name, SSN, or date of birth.
• Has the client provided informed consent to share information with the receiving organization?
• Date Consent Was Obtained
  Required if consent is 'signed' or 'verbal'.
• What information was shared with the receiving organization?
  Select only what was actually transmitted. Collect the minimum necessary.

Receiving Organization Details

• Receiving Organization / Program Name
• Service Category
  Primary service type the client is being referred for.
• If 'Other', describe the service category
• Receiving Organization Contact Name
• Receiving Organization Phone Number
• Was an appointment or intake scheduled at time of referral?
• Scheduled Appointment Date
  If an appointment was confirmed, record the date.
• Referral Notes
  Describe the presenting need, any barriers noted, or special instructions for the receiving organization. Avoid recording PII not covered by the consent obtained above.

Warm Handoff Documentation

• Was a warm handoff completed?
  A warm handoff involves direct staff-to-staff or staff-to-client-to-staff introduction, not just a resource list.
• Were any barriers to a full warm handoff encountered?
  Select all that apply.
• Planned Follow-Up Contact Date
  Set the date by which staff will contact the client or receiving organization to verify connection. Best practice: within 3–7 business days of referral.
• Planned Follow-Up Method

Follow-Up Contact and Closed-Loop Verification

• Has follow-up contact been completed?
• Actual Follow-Up Contact Date
• Who was contacted for follow-up?
• Did the client connect with the referred service?
  This is the closed-loop verification question.
• Describe the barrier encountered
• Is a re-referral or alternative resource needed?
• Follow-Up Notes
  Summarize the follow-up conversation, any next steps, and the current status of the referral. Avoid recording PII beyond what is necessary.

Outcome and Case Status

• Overall Referral Outcome
  Select the final status of this referral record.
• Referral Close Date
  Date this referral record is being closed. Leave blank if still open.
• How would you rate the quality of this referral process?
  Internal quality indicator for continuous improvement. 1 = significant gaps; 5 = seamless warm handoff and confirmed connection.
• Process Improvement Notes (Internal)
  Optional: note any systemic issues, partnership gaps, or process improvements identified through this referral. Used for QI review only.

Audit Trail and Certification

• Name of Staff Completing This Form
• Role / Title
• Does this referral require supervisor review?
  Flag for supervisor review if the referral involved a safety concern, mandatory reporting, or a re-referral after failed connection.
• Reason for Supervisor Review
• Certification
  By submitting this form, I certify that the information recorded is accurate and complete to the best of my knowledge, that consent was obtained as documented, and that this record was created in accordance with agency policy and applicable privacy regulations (HIPAA, 42 CFR Part 2 where applicable).
• Date of Submission
  Date this form is being submitted.