The GOAT Code Intake & OhioRISE Respite Interest Form

The GOAT Code Intake & OhioRISE Respite Interest Form

Share your family’s information and what support your child needs so we can connect you to the right next steps.
Parent/Guardian Information
Parent/Guardian Name

First NameMiddle NameLast Name
Relationship to Youth
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Best Days/Times to Contact
Youth Information
Youth full name

First NameMiddle NameLast Name
Preferred name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
School
Grade
Youth address (if different from parent/guardian address)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medicaid status
Medicaid plan
Medicaid ID (if available)
Currently enrolled in OhioRISE
Has OhioRISE care coordinator
Care coordinator name

First NameMiddle NameLast Name
Agency
Care coordinator phone
Please enter a valid phone number.Format: (000) 000-0000.
Care coordinator email
example@example.com
Referral source
Respite Interest
Preferred days for respite
Do you need transportation help?
Behavioral Health Interest
This section is to help us understand what kind of support your family is looking for. Some services are one-on-one, some are group-based, and some are respite-focused.
Which services are you interested in?
Current concerns
Goals for behavioral health services
Diagnoses the parent or guardian would like to share
Current providers and agencies
Current medications, if relevant
Recent hospitalizations, emergency visits, or crises
School concerns
Behavioral concerns
Mental health concerns
Developmental needs
Communication needs
Sensory needs
Allergies or dietary restrictions
Medical conditions or mobility/accessibility needs
Safety concerns, triggers, calming strategies, elopement risk, aggression risk, or self-harm concerns
Anything staff should know to support the youth safely
Additional information
Availability and Scheduling Preferences
When would you like services to start?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred service frequency
Preferred weekend time

Hour Minutes

AM/PM Option
Which services are you interested in?
Additional scheduling preferences or availability details
Consent, Acknowledgments, and Sign-Off
Permission to contact parent/guardian
Permission to coordinate with OhioRISE care coordinator, school, referral source, and current providers only after a separate release is signed
Acknowledgment of program limits and conditions
What would make The GOAT Code a successful and supportive experience for your child?
Electronic signature
Printed name

First NameLast Name
Should be Empty:

The GOAT Code Intake & OhioRISE Respite Interest Form

Parent/Guardian Information

Youth Information

Respite Interest

Behavioral Health Interest

Availability and Scheduling Preferences

Consent, Acknowledgments, and Sign-Off