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Strengthening Families Through Services

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GET STARTED AT INSPIRE TO RISE

Have a Referral for Inspire to Rise?

Referral for Services

Referral Date*

Month

Day

Year

Participant Information

First name*

Last name*

Birthday

Month

Day

Year

Email*

Phone*

Gender

Address

Preferred Method of Contact

Text

Call

Email

Is the Above Participant a Minor?

Does the Person Being Referred Have a Caregiver?

Yes

No

Referring Agency Information

How Were You Referred to Inspire to Rise?

Insurance Information

Individual/Family Insurance

Self

Spouse

Dependent

Parent/Guardian

Agency

Self Pay

Other

Reason for Referral

Community Center Services (Check all that apply)*

Parenting Assessment

Nurturing Parenting Program Group

Individualized Parenting

Supervised Visitation

Coached Supervised Visitation

Therapeutic Visitation

Safety Support Services

Healthy Start - Parenting Education & Support Program

Psychiatric Evaluation

Med Management

Individualized Therapy (Child or Adult)

Couples/Family Therapy

Psychosocial Rehabilitation Classes

Substance Abuse Assessment

RISE Substance Misuse Treatment Services

RISE Family: In-Home SA & MH Services

Peer Recovery Support Services

Peer Support Group

Group Life Skills

Community Partnership Classes

IY Afterschool Program

The INSPIRED Youth Prevention & Recovery Day Program (IY)

Other

Background Information

Please Explain Reason for Referral

Do any of the following apply to the person being referred (please check all that apply).

Learning Disability

Deaf and/or Hard of Hearing

Blind/Vision Impaired

Active Substance Use

History of Substance Abuse

Other

Spoken Language

I understand that missed or cancelled appointments with less than 24-hour notification are subject to a $30.00 cancellation/no-show fee.

Call Us Toll-Free: Email Us:

1-844-WE-RISE-1 info@inspiretoriseinc.org

(1-844-937-4731)

Find Us:

Inspire to Rise, Inc. - Westside (Main Campus)

5927 Old Timuquana Road, Jacksonville, FL 32210

Inspire to Rise, Inc. - Northwest

2901 Commonwealth Avenue, Jacksonville, FL 32254

Inspire to Rise, Inc. - Nassau County

@ FSS Nassau Service Center

96016 Lofton Square Ct, Yulee, FL 32097

Inspire to Rise, Inc. - Clay County

7175 Hwy 17, Suites 3-4, Fleming Island, FL 32003

OD2A is a grant-based program with 100% of its funding from the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS).

Inspire to Rise, Inc. is proudly sponsored by:

www.Duval.FloridaHealth.gov

Florida Health: the first accredited public health system in the U.S.

On 6/22/22, Inspire to Rise, Inc. earned The Joint Commission’s Gold Seal of Approval® for Behavioral Health Care and Human Services Accreditation by demonstrating continuous compliance with its performance standards. The Gold Seal is a symbol of quality that reflects a health care organization’s commitment to providing safe and quality patient care.

Inspire to Rise, Inc. is accredited by:

Inspire to Rise, Inc. - Privacy Policy

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