● Applications are open. Start your journey with I2E today. Apply now →
Referral

Submit a referral.

Referrals are made by County and State DHR. Fill out the form below to start the process for a youth in your care.

All fields on this form are required. Submissions are emailed directly to our team.

Youth Information
High school diploma, GED, or N/A *
Driver's license, permit, or N/A *
Criminal history? *
Youthful offender or adult offender *
Active probation? *
Bank account? *
Checking, savings, both, or N/A *
Employed, unemployed, or disability *
Pursuing college or vocational training? *
HOPE/EV Scholarship? *
Health Conditions

Check any that apply to the youth being referred.

County DHR
Authorization
I hereby authorize: (1) the release of current psychological, comprehensive family assessment, individual service plan, education, and medical records to OT2GO and OT2GO Innovation to Elevation Daily Living for the purpose of obtaining authorization for services to be rendered or for the payment of insurance claims (2) authorize release of medical and behavioral health information between OT2GO and OT2GO Innovation to Elevation Daily Living, CDHR, SDHR, physicians, and insurance company(-ies) that may require filing of an insurance claim or appeal a claim on my behalf (3) authorization to the insurance company to pay OT2GO and OT2GO Innovation to Elevation Daily Living. I hereby authorize future contact for care from OT2GO and OT2GO Innovation to Elevation to Daily Living, follow up, and continual treatment, regarding the services to be provided. The plan of care allows for OT2GO and OT2GO Innovation to Elevation Daily Living to continue this contact, at any future time, while services are rendered.
Policy Acknowledgement *

Please check the boxes below to confirm that you have read and understood the following policies. By checking these boxes, you acknowledge that you have reviewed and comprehended the policies outlined by OT2GO and OT2GO Innovation to Elevation Daily Living. It is essential to familiarize yourself with these policies to ensure a clear understanding of our practices and commitments to your privacy. If you have any questions or concerns, please don't hesitate to contact our office.