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Run: Referral Tracking and Closed-Loop Verification Form

Track outgoing and incoming referrals, document consent and PII handling, and verify whether the client actually connected to the receiving service. Built fo...

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Referral Record

Referral ID / Case Number (required)

Internal case or referral identifier. Do not enter the client's full name or SSN in this field.

Referral Direction (required)

Is this an outgoing referral you are sending, or an incoming referral received from a partner?

Date Referral Was Made (required)

The date the referral was initiated or received.

Referral Method (required)

How was the referral communicated?

If 'Other', describe the referral method

Referring Staff Member Name (required)

Referring Staff Role / Title

Client Consent and PII Handling

Client Identifier (Non-PII) (required)

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? (required)

Date Consent Was Obtained

Required if consent is 'signed' or 'verbal'.

What information was shared with the receiving organization? (required)

Select only what was actually transmitted. Collect the minimum necessary.

Receiving Organization Details

Receiving Organization / Program Name (required)

Service Category (required)

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? (required)

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? (required)

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 (required)

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 (required)

Follow-Up Contact and Closed-Loop Verification

Has follow-up contact been completed? (required)

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 (required)

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 (required)

Role / Title (required)

Does this referral require supervisor review? (required)

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 (required)

Date this form is being submitted.

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