OhioRISE Referrals

  Once referred, Unison Health will work to complete the CANS Assessment to determine program eligibility.  
County
Name of person making referral
Name of Child being referred
Child Date of Birth
Contact number of person making referral
Email of person making referral
Name of Guardian
Guardian Phone Number
Guardian Email Address
Child Sex
  Male
 Female
 Unkown
Medicaid ID (Optional)
Child Physical Address
City/State/Zip
Comments

Unison Health will not use the phone number submitted via this form for text messaging. You may be able to Opt-In to text messaging with Unison Health at a later time.