The Equi Institute Referral Form 
This form is for external referrals for participants seeking support from a Certified Recovery Mentor at The Equi Institute in the Recovery Support and Harm Reduction Program. 

Please note that not all questions are required, or there are options for non-disclosure. Individuals are supported in answering to the degree of their comfort level. We believe in moving at the speed of trust. Self-disclosure on personal matters is up to the participant. 

If the referring provider or organization is providing any past or current services to the client, please include a Release of Information (ROI) form to aid continuity of care. (Reach out to The Equi Institute for access to a form if you have not already been sent an ROI.) 

If you have any questions, please contact info@equi-institute.org or 503-459-2584.
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Date of referral *
MM
/
DD
/
YYYY
Referring agency/provider *
Referring agency/provider contact information  *
Participant's used/preferred name *
Participant's name on their ID or insurance (if comfortable or if it differs) 
Participant's date of birth *
MM
/
DD
/
YYYY
Participant's pronouns *
Required
Gender - check all that apply *
Required
Are you transgender? *
Required
How would you describe your racial or ethnic identity? 
Participant's contact information and preferred method (call, text, e-mail, or other) 
Is it okay to contact you?  *
What services or support are you currently engaged in? If none, please write 'none'. 
What language or languages do you use? Do you need an interpreter for us to communicate with you? 
What services and supports are you most interested in? (check all that apply)  *
Required
Current living situation
Does participant have health insurance
Does participant have any immediate emergency substance, housing, social/domestic safety needs? If yes, please describe. 
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