Module 3 Assignment 1

Module 3 Assignment 1: Resource List for Referrals

Activity Directions

  1. Fill in all of the missing contact information on the BHA/P List of Resources
  2. Click here for a Word document containing this form
  3. Complete you resource list in a word processing program (eg. Word) and save it in the BHA folder you created on your desktop.
  4. Drag your completed BHA/P List of Resources into the Assignment area to submit it.

Once created, you will have a convenient list of contacts to use when assisting clients. This assignment is also designed to help you become more familiar with the resources available to your clients.

BHA/P List of Resources

Emergency Services

Referral Type

Contact Information

Contact Information

Medical



Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Law Enforcement

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Crisis Line

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Other

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Mental Health

Referral Type

Contact Information

Contact Information

Individual Therapy

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Family Therapy

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Mental Health (continued)

Group Therapy

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Substance Abuse Treatment

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Local Support Group

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Medical

Referral Type

Contact Information

Contact Information

CHA/P

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Medication Management

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Traumatic Brain Injury

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Nutritional Guidance

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Medical (continued)

Other Medical Needs

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Testing and Assessment

Referral Type

Contact Information

Contact Information

Neuropsychological

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Academic

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Speech/Language

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Fetal Alcohol Spectrum Disorder

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Social Services

Referral Type

Contact Information

Contact Information

Transportation Assistance

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Social Services (continued)

Head Start/Preschool

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Educational Assistance

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Legal Assistance

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Transitional Services

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Vocational Training

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Subsistence Activities

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Domestic Violence (Shelter/Services)

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

Sexual Assault Response

Organization:

Contact Name:

Phone:

Email:

Organization:

Contact Name:

Phone:

Email:

You can respond using Word and dragging your file into the response box.

Directions: 

1. Download and save the BHA/P List of Resources file to a folder on your computer desktop.

Fill in all of the missing contact information and save your updated resource list.


2. Click on the 'Add Submission' button below, to see the  file response area

3. Drag your file into the file area

4. You are able to upload up to 5 files of a maximum size 5 MB each

5. Click 'Save Changes' and you are done!