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Run: Community Resource Referral Log

Log each community resource referral in one place, from consent and contact method to follow-up status and outcome notes. Use it to coordinate housing, emplo...

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Referral Record

Referral Date (required)

Referral Source (required)

Primary Reason for Referral (required)

Select all that apply. Collect only what is needed for care coordination.

Referral Summary

Briefly describe the need and any relevant context. Avoid unnecessary PII.

Person and Consent

Person's Name

Optional if your workflow allows anonymous submission or uses an internal identifier instead of a name.

Internal Client or Case ID

Use an internal ID instead of collecting extra PII when possible.

Preferred Contact Method

Consent to Share Referral Information (required)

Required before sharing any PII with an external resource provider.

Consent Notes

Document any limits on consent, disclosures provided, or preferred communication boundaries.

Resource Referral Details

Resource Category (required)

Resource or Provider Name (required)

Referral Method (required)

Scheduled Appointment Date

Resource Contact Information

Optional. Include only if needed for follow-up coordination.

Follow-Up and Outcome

Is Follow-Up Needed? (required)

Follow-Up Due Date

Current Follow-Up Status (required)

Outcome Notes

Document outreach attempts, barriers, and next steps without unnecessary PII.

Number of Outreach Attempts

Status, Escalation, and Audit Trail

Referral Status (required)

Escalation Needed? (required)

Escalation Reason

Audit Trail Notes

Record key actions, dates, and handoffs for the referral history.

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Email (required)

Your name (optional)

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