**Sample Referral Tracking Template**

**Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ^®X702^Date of Referral
\_\_\_\_/\_\_\_\_/20\_\_\_ ^®H09^Worker ID \_\_\_\_\_\_ Client ID
\_\_\_\_\_\_\_\_\_**

(Fill out 1 form for each referral)

**^®X703^Referral Service Type**

01 HIV Testing 14 Partner counseling and referral services

02 HIV Confirmatory test 15 Mental Health Services

03HIV prevention counseling 16 Comprehensive Risk Counseling & Services

04 STD screening and treatment 17 Other prevention services

05 Viral Hepatitis screening / treatment 18 Other support services

06 Tuberculosis testing 88 Employment Assistance

07 Syringe exchange services 88 Foodbank

08 Reproductive health services 88 Case Management (e.g., Ryan White,
SAMSA, Medicaid)

09 Prenatal care 88 Housing Assistance

10 HIV medical care / evaluation / treatment 88 Legal Assistance

11 IDU risk reduction services 88 Child care assistance

12 Substance abuse services 88 Clothing assistance

13 General medical care 88 Other (specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Referral Agency Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^®X705^Referral Follow-up Plan**

00 No- follow-up There is no plan to verify that the client accessed
this referral

01 Active referral The referring provider will directly link the client
to the service provider or agency

02 Passive referral The referring provider will confirm the outcome of a
referral through information received by

(agency verifies) the receiving agency.

03 Passive referral The referring provider will confirm the outcome of a
referral through information provided by

(client verifies) the client.

**^®X706^Referral Outcome**

01 Pending The referring agency has not yet confirmed whether the client
accessed the service to which

he or she was referred.

02 Confirmed The referring agency has confirmed whether **[the client
accessed]{.underline}** the service to which he or

she was referred.

03 Confirmed The referring agency has confirmed that **[the client had
not accessed]{.underline}** the service to which

he or she was referred.

04 Lost to follow-up Within 60 days of the referral date (Referral Date
\< 60), access of the service to which the

client was referred can't be confirmed or denied. The system will
automatically mark a

referral as "lost to follow-up" if a referral has not been verified
within 60 days of the referral

date.

05 No follow-up The referral was not tracked to confirm whether the
client accessed the referred service.

**^®X710^Referral Close Date**

The date the outcome of the referral was confirmed or lost to follow-up.
\_\_\_\_\_/\_\_\_\_/20\_\_\_\_

**^\*X7221^Reason referral was not completed**

01 No Reason/just didn't try/Not interested 14 No phone / regular
address

02 No time/too busy/put it off 15 Staff was rude / insensitive

03 Did not like the agency 16 Language barrier

04 Agency hours not good 17 Intake process too complicated

05 Never filled out forms 18 Too long a wait

06 Not enough info on availability 19 Missed appointment

of service or location 20 Too much trouble / work

07 No transportation 21 Confidentiality issues

08 Tried, but not eligible 22 Too ill to go

09 Put on hold/complicated voicemail 23 Felt well /did not need service

10 Fear/anxiety 24 Lack of trust in provider

11 Wait list/no appointment soon enough 25 No Health Insurance

12 Services not at referred agency 26 Too expensive

13 Given incorrect information Other (specify)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**^\*7222^Other Services Provided**

02 Made an appointment for client

03 Sat with client while telephoned agency

04 Provided general referral agency info

05 Provided referral slip

06 Provided referral to specific agency/person

07 Discussed service options with clients

08 Arranged for social worker/case manager to assist

09 Provided transportation voucher

10 Help client complete forms

11 Provided agency location info/map

88 Other (specify) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Case Notes**
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**Counselor Signature**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **Date** \_\_\_ /
\_\_\_\_/20\_\_\_