Worksheet Under constructionCriterion 34 begins the community engagement function with care coordination. A client may need medical, psychological, recovery, social, or spiritual support beyond the facilitator's own services. This module describes identifying those needs, checking possible referrals, helping the client make contact, and communicating within the agreed limits on information sharing. Research on collaborative care provides relevant context, although the structured clinical models studied are more extensive than ordinary referral work. Criterion 35 then examines how to discuss the role of community with the client.
Learning Objectives
By the end of this module, the trainee will be able to:
- Describe the findings of the collaborative care review and the limits of applying them to referral work.
- Distinguish coordinating services (this criterion) from providing them (outside facilitator scope).
- Identify the categories of service a client may need: medical, psychological, recovery, social, spiritual.
- Vet a service for competence, safety, and fit before referring a client to it.
- Make a warm referral that lowers the barrier to a client actually connecting.
- Apply the consent and confidentiality architecture that sharing client information across providers requires.
- Coordinate among multiple providers without overstepping scope or taking over the client's care.
- Recognize referral as the mechanism for getting a client to care the facilitator cannot provide, including urgent care.
- Address common barriers: accessibility, client resistance, and the temptation to overstep.
- Maintain a current, vetted resource map for the facilitator's region and the online options beyond it.
Key Terms
Care coordination. Helping the client reach appropriate services and arranging communication within the agreed roles and permissions.
System of care. The web of medical, psychological, recovery, social, and spiritual services that, working together, supports a client's healing beyond what any single facilitator or program can provide.
Scope boundary. The limits set by a facilitator's qualifications, competence, and role. Care beyond those limits requires an appropriately qualified provider.
Vetting. Checking a service's qualifications, reputation, practices, and suitability for the client's needs before making a referral.
Warm referral. Assistance that helps the client make contact with a service, such as a specific name, an introduction with permission, help drafting a message, or an explanation of what to expect.
Release of information. Documented permission to share specified information with a named provider for an agreed purpose, subject to applicable confidentiality requirements and lawful exceptions.
Collaborative care. An organized clinical model involving coordinated treatment by several professionals. The model studied by Archer et al. (2012) includes more extensive clinical arrangements than ordinary referral assistance.
Resource map. The facilitator's maintained, current inventory of vetted local, regional, and online services across categories, which makes timely, appropriate referral possible.
Core Teaching
Recognizing needs beyond the program
A client may need support for concerns that extend beyond the psychedelic experience. These can include a medical condition, unresolved trauma, substance use, a relationship crisis, or difficulty with housing and finances. Ask about the wider circumstances and identify which needs require another professional or service.
Care coordination involves helping the client reach that support and clarifying how the services can work together. The facilitator needs to understand their own role, the receiving provider's role, and the client's preferences. A referral should provide a route to care the client can use, with appropriate follow through when help is needed to make the connection.
Research on collaborative care
Archer et al. (2012) reviewed 79 randomized trials involving more than 24,000 participants and found benefits from collaborative care for depression and anxiety compared with usual care. Benefits for depression were observed for up to two years, although the review also identified methodological limitations in some trials. Collaborative care in that literature involves organized clinical treatment with several components and professional roles.
The finding provides context for attending to communication and continuity across services. It does not establish that a facilitator making referrals is delivering the studied model or will produce the same outcomes. This criterion applies practical coordination responsibilities within the facilitator's scope, with that difference in the evidence kept clear.
Identifying appropriate services
Consider the range of services the client may need and how urgently they need them. Medical care can include primary care, specialist assessment, and required monitoring. The cardiac concerns associated with ibogaine and the interaction risks discussed in Criteria 1 and 2 require appropriate medical involvement. A medication question belongs with a qualified prescriber.
Mental health services may include psychotherapy, psychological assessment, or psychiatric care. Recovery services can provide addiction treatment and peer support. Housing, financial, legal, and family services may address conditions that interfere with the client's stability. Spiritual or cultural communities may provide continuity and support that the person values. Discuss these possibilities with the client and identify what is already in place before adding more referrals.
Ask what care the client already receives and whether they want help connecting the parts. A therapist or prescriber who knew them before the experience may have useful information about their usual functioning. With permission, that continuity can help clarify what is new and what has been present for some time. The facilitator can help the client describe the experience in terms relevant to the receiving professional, including timing, symptoms, and changes in daily life.
The referral discussion should include the client's concerns about being understood. They may worry that a clinician will dismiss a spiritual experience or that a psychedelic practitioner will dismiss an adverse effect. Ask what they want the provider to understand and help them prepare questions for the first contact. Respectful interest in psychedelic experiences is one part of fit; the provider also needs competence in the actual problem being referred.
Checking a referral
Before recommending a service, check its qualifications, relevant experience, and suitability for the client's concern. Confirm professional licensing and standing where applicable, look into credible concerns about conduct, and learn what the service actually provides. An encouraging reputation or a familiar name is not enough to establish competence in the specific care required.
Fit also includes language, access, values, and the provider's ability to discuss psychedelic experiences respectfully. Ask the client about preferences and prior experiences that should inform the choice. Where information is incomplete, say what you have and have not been able to establish. Do not promise safety or quality beyond what the available information supports, and continue looking for a better supported option when there are unresolved concerns.
Different services offer different kinds of support. Fireside Project provides peer support during and after psychedelic experiences. Pleet et al. (2023) reported encouraging responses from people who used its helpline, but the study relied on a voluntary survey and did not establish that particular emergency visits were prevented. Peer support can be considered among the client's resources when it fits their needs. Current availability and service limits should be checked directly when making the referral.
Being True To You describes integration coaching and explicitly states that its coaching does not replace professional medical care (Being True To You, n.d.). When comparing coaching with psychotherapy or psychiatric services, explain what each provider is qualified to do and what the client is seeking. A client may reasonably use more than one service if responsibilities are clear. None should be presented as interchangeable simply because each uses the word integration.
Helping the client make contact
A client who is distressed or unfamiliar with a service may need help with the first contact. Provide the name and contact details, explain why the service was suggested, and ask what assistance would be useful. The client may want help drafting a message, understanding the intake process, or making an introduction with permission.
Describe what you know about the service without guaranteeing how the relationship will go. At the agreed follow up, ask whether the client made contact and whether barriers remain. If the first option is unavailable or does not fit, help them consider another. The referral process can continue until the client has an appropriate route to support, within the boundaries of the facilitator's role.
Close the referral process with an agreed follow up. Ask whether the service responded, whether an appointment was offered, and whether the cost and timing are manageable. A referral can fail after the first call because the waiting list is long or the provider does not address the concern described. If that happens, discuss another route and identify who is responsible for the next contact. Do not record a need as resolved solely because a telephone number was supplied.
For a routine referral, the client may prefer to make contact independently and report back. For a more urgent concern, follow the program's escalation procedure and communicate the urgency to the appropriate service. A peer line, an integration group, and an emergency service have different capacities. Keep those distinctions clear when planning support so that a client with an acute concern is not left waiting for an ordinary appointment.
Consent and information sharing
For routine coordination, obtain the client's informed, documented authorization before sharing information with another provider. Discuss which provider may receive it, what information is relevant, and the purpose of the contact. Share only what the coordination requires and what the authorization permits.
Permission to communicate with a therapist does not authorize contact with an employer or family member. Explain how the client can withdraw permission and the limits on reversing information already disclosed. Follow the applicable professional and legal requirements, including any authorized or required safety disclosures. These arrangements extend the consent foundations of the intake criteria and the confidentiality work in Criterion 28.
Maintaining a clear role
Once services are involved, the facilitator may help clarify contact arrangements, check whether the client has reached care, and identify gaps that still need attention. With the appropriate authorization, communication can help providers understand the relevant context and avoid leaving the client to repeat everything or resolve conflicting information alone.
Clinical decisions remain with the professionals responsible for that care. Coordination does not authorize the facilitator to direct medication changes, deliver an untrained therapy, or manage another provider's treatment. Help the client understand the arrangement and participate in it. As they become more able to navigate the services, review what assistance remains useful.
When providers need to communicate, prepare a concise handoff within the client's authorization. Include the reason for contact, the relevant timing, observed changes, and what has already been done. Clearly attribute the client's account and identify any information that is uncertain. An account of a vision or a facilitator's interpretation is usually less useful to a medical assessment than a clear description of symptoms and their course. Share further detail only when it is relevant and authorized.
Disagreement between services can leave the client unsure whose advice to follow. Help identify the actual point of disagreement and direct treatment questions to the responsible clinician. A coach who hears conflicting medication advice should support clarification with the prescriber. They should avoid settling the disagreement from their own reading or encouraging the client to stop treatment to preserve the meaning of an experience.
Access and the referral network
Cost, insurance, transportation, language, disability, and location can make a theoretically suitable service inaccessible. Ask about those constraints early and include affordable, remote, or otherwise accessible alternatives where appropriate. A client may also be wary after previous harmful or disappointing care. Listen to those concerns and discuss a first contact they are willing to consider without pressuring them into the facilitator's preferred service or community.
Maintain a current list of local, regional, and online resources across the categories clients may need. Record relevant qualifications, contact details, access information, and the date information was checked. Relationships with providers can help make introductions, but they should not replace evaluation of fit. Update the list when availability, services, or concerns about quality change.
Longer lasting problems may require a different referral from the one anticipated during preparation. Evans et al. (2023) documented extended difficulties after psychedelic experiences in a selected sample, including anxiety and depersonalization or derealization. Their findings support having referral options for persistent distress. They do not establish a particular treatment or imply that every unsettled experience will become a disorder.
Review gaps in the resource map after actual referrals. A provider may be listed as accepting clients while offering no appointments at the times clients can attend. An online option may require technology or privacy they lack. Record these barriers, keep the information current, and bring recurring gaps to the program's attention. Improving coordination can involve developing a relationship with an accessible service as well as adding another name to a list.
Care while a referral is pending
A referral can be accepted while the first appointment remains days or weeks away. Agree who is responsible for contact during that interval and what the referring program can provide. Confirm the receiving service’s appointment details, eligibility requirements, and available urgency pathways. If the client’s condition changes, reconsider whether waiting remains appropriate. A booking confirmation cannot establish that the present level of support is sufficient.
Give the client a short, usable contact plan with the next appointment, the person or service to contact with a concern, and the hours that contact is monitored. Include the local route for urgent medical or mental health assistance and what to do if the planned service is unavailable. Check location when arranging remote support because the relevant emergency services depend on where the client actually is. A peer support line may offer conversation and connection; its availability and remit must be checked directly, and it cannot replace an emergency response.
Discuss missed contact in advance. Ask whether a reminder, voicemail, message, or contact with a nominated support person is acceptable, and record any privacy restrictions. If an appointment is missed, follow the agreed plan and reassess any known concern. Avoid promising continuous monitoring that the service does not provide. When care transfers, confirm with the client and the receiving service, within the agreed information sharing arrangements, who will handle the next step. Document any gap that remains unresolved and the action being taken.
Clinical and Decision Tools
Tool 1. Coordination and clinical responsibilities
The examples distinguish coordination tasks from treatment decisions that require the relevant professional qualifications. Apply the boundary to your own role and training.
Coordination task | Clinical responsibility requiring appropriate qualifications |
|---|---|
Help the client reach psychotherapy | Assess and provide the psychotherapy |
Refer a medication question to a prescriber | Advise on medication changes or tapering |
Connect the client with addiction treatment | Assess and deliver the treatment |
Arrange permitted communication between providers | Make clinical decisions within each provider's role |
Tool 2. Categories of service to hold in view
Consider the client's broader circumstances and the urgency of each need. Medical and psychiatric concerns may require prompt professional involvement.
Category | Examples | Consideration |
|---|---|---|
Medical | Primary care, specialists, laboratory assessment | Assess referral urgency; attend to relevant medication and cardiac concerns |
Mental health | Therapist, psychologist, psychiatrist | Match qualifications and expertise to the client's needs |
Recovery | Addiction treatment and peer recovery support | Discuss the client's preferences and required level of care |
Social | Housing, financial, legal, and family services | Address practical needs that affect stability and access |
Spiritual or cultural | Community, mentor, or tradition | Ask what fits the client's identity and wishes |
Tool 3. Vet before you refer
Check the service before recommending it. Explain any unresolved uncertainty that affects the client's decision.
Question | If the answer is uncertain or unsuitable |
|---|---|
Are required qualifications current, and is there a sound professional record? | Check further or identify another service |
Does the provider have expertise relevant to this need? | Find a service with suitable competence |
Does the service fit the client's preferences and safety needs? | Discuss the concern and consider alternatives |
What do I know firsthand, and what remains unverified? | Explain the limits of your knowledge and complete further checks |
Tool 4. Permission to share information
Before routine information sharing, establish the client's permission and its limits. Explain any applicable legal exceptions and how permission can be withdrawn.
Before routine information sharing | Arrangement to establish |
|---|---|
Permission | Obtain and document informed permission before contact |
Limits | Identify what may be shared, with whom, and for what purpose |
Information needed | Share only what is necessary for the agreed coordination |
Withdrawal and exceptions | Explain how permission can be withdrawn and the limits of confidentiality under applicable requirements |
Tool 5. Care coordination checklist
Review the services identified, checks completed, permissions obtained, and help offered with making contact.
Check | Done? |
|---|---|
Needs identified across relevant service categories | Yes / No |
Qualifications, practices, and suitability checked | Yes / No |
Practical help offered with making contact | Yes / No |
Permission for routine information sharing documented | Yes / No |
Sharing limited to the agreed purpose and necessary information | Yes / No |
Receiving providers' clinical responsibilities respected | Yes / No |
Access concerns and preferences discussed with the client | Yes / No |
Resource information checked for currency | Yes / No |
Worked Example: Coordinating a System of Care
This fictional example considers medical, psychological, and community needs, followed by referral and communication arrangements.
Context: Integration reveals that a client is carrying unresolved trauma, a possible cardiac concern the client has never had checked, and deep isolation since leaving a religious community they still miss.
Reading the whole person: The facilitator recognizes three distinct needs across categories: ongoing trauma therapy (mental health), a medical evaluation of the cardiac symptom (medical, and potentially safety relevant), and reconnection to community (spiritual and social). None is within the facilitator's scope to treat.
Checking referrals: The facilitator identifies a licensed trauma therapist with relevant experience and an affordable primary care option. They ask the client about their wishes concerning spiritual community and discuss suitable possibilities.
Permission to communicate: The facilitator explains the proposed contact with the therapist and documents the client's authorization for specified information. The client declines family involvement, and the facilitator respects that decision.
First contacts: With permission, the facilitator makes an introduction to the therapist and helps the client prepare a message for the medical office. They explain what is known about the intake process and ask what other assistance would help.
Medical concern: The facilitator directs the client toward appropriate medical evaluation and follows the site's escalation procedure if urgent signs are present. They do not diagnose the symptom or treat an unassessed cardiac concern as a routine integration issue.
Staying in the coordinator role: The facilitator organizes the connections and then steps back, checking in on whether the client reached each service without inserting themselves into the therapy or the medical care, and orienting the client toward navigating these relationships themselves over time.
Case Vignettes
For each vignette, identify the concern, consider the client’s needs, and describe how you would respond. Use the companion worksheet when available, or record your responses separately.
Vignette A
A client discloses a serious untreated medical symptom during integration. The facilitator offers an explanation of the likely cause and suggests supplements. The facilitator has no medical qualification and does not arrange a referral.
Guided questions: Which actions exceeded the facilitator's qualifications? What medical assessment was needed? How should the urgency of the referral be addressed?
Vignette B
Wanting to help quickly, a facilitator calls a client's former therapist to share what came up in ceremony and coordinate care, without first obtaining the client's consent to contact them. The client, who had complicated feelings about that therapist, feels violated when they find out.
Guided questions: What consent step was skipped? Why does coordinating care cross the confidentiality boundary? What should have preceded any contact?
Vignette C
A facilitator tells a struggling client they should find a therapist and get some support, and leaves it there, offering no names, no help, and no follow up. The overwhelmed client never makes a call, and their distress deepens over the following weeks with no support in place.
Guided questions: What made contacting a therapist difficult for this client? What practical assistance could have helped? How could the facilitator follow up within their role?
Vignette D
A facilitator refers every client to the same spiritual community the facilitator personally belongs to, regardless of the client's own background or beliefs, presenting it as the natural next step. A client from a different tradition feels subtly pushed and quietly disengages.
Guided questions: How did the facilitator overstep? Whose preferences were being served? How should community options have been offered?
Vignette E
A facilitator refers a vulnerable client to a psychedelic integration practitioner they found online but never vetted. The practitioner turns out to be unqualified and ethically careless, and the client is harmed by the very referral that was meant to help.
Guided questions: What responsibility did the facilitator skip? Why does vetting matter especially in an unevenly regulated field? What would due diligence have involved?
Role Play and Practice Scripts
Practice in pairs, then switch roles. Explain a referral, discuss permission to communicate, offer practical help, and ask about the client's preferences.
Referring a medical concern without overstepping
The partner discloses a physical symptom. Practice saying, “That needs medical evaluation. I can help you contact an appropriate service.” Discuss how urgency would be determined under the site's procedures and what would require immediate escalation, without offering a diagnosis.
Securing consent before coordinating
“Would you like me to contact your therapist about the work here? Before I do, we should agree on exactly what you want shared and what you want kept private.” Practice documenting the recipient, information, purpose, and limits of the authorization.
Making a warm referral
“This service may fit what you've described. I can explain why I suggested it and what I know about the intake process. Would you like help making the first contact?” Let the partner decide what assistance they want.
Offering community options without steering
“What kind of group or community would you feel comfortable trying? We could look at peer support, a cultural or faith community, or something built around an activity you enjoy.” Explore the client's preferences and prior experiences before suggesting a particular option.
Care while a referral is pending
A referral has been accepted, but the first appointment is in two weeks and the client’s symptoms are worsening. Practice clarifying the current need, arranging the appropriate level of assessment, and explaining who can be contacted in the meantime.
Self Assessment and Reflection
Knowledge check
Describe the collaborative care evidence cited here and explain its relevance and limits for a facilitator's referral work.
Distinguish coordinating a service from providing it, with an example of each.
Name the categories of service a client may need and why medical and mental health needs carry particular weight.
Explain what vetting a service involves and why it matters especially in this field.
Explain the difference between a bare suggestion and a warm referral.
Describe the permission and confidentiality arrangements needed for routine communication across providers.
Explain how a facilitator can provide enough help with referrals while respecting the receiving providers' clinical responsibilities.
Reflection
How well do you actually know the vetted services in your region and online? Where is your resource map thin?
Are you more prone to abdicating (a list and goodbye) or over functioning (managing care that is not yours)? How will you correct it?
Where might you be tempted to steer a client toward your own preferred community or practitioner? How will you offer genuine options instead?
Summary
Care coordination helps the client reach services that meet needs beyond the facilitator's own work. Identify the concerns and their urgency, check potential services, and discuss the client's preferences and access requirements. Research on collaborative care supports structured approaches in depression and anxiety treatment, while its findings do not establish the effects of ordinary referral coordination in psychedelic facilitation (Archer et al., 2012).
Assist with first contacts where useful and check whether the client reached the service. Routine information sharing requires appropriate authorization specifying the recipient, purpose, and content. Stay within the coordinating role and leave treatment decisions to the qualified providers responsible for them. A current referral network and attention to practical barriers make it easier to arrange support when it is needed.
References
Sources
Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 2012(10), CD006525. https://doi.org/10.1002/14651858.CD006525.pub2
Being True To You. (n.d.). Personal transformation & psychedelic integration. Retrieved September 18, 2026, from https://beingtruetoyou.com/
Evans, J., Robinson, O. C., Argyri, E. K., Suseelan, S., Murphy-Beiner, A., McAlpine, R., Luke, D., Michelle, K., & Prideaux, E. (2023). Extended difficulties following the use of psychedelic drugs: A mixed methods study. PLOS ONE, 18(10), e0293349. https://doi.org/10.1371/journal.pone.0293349
Pleet, M. M., White, J., Zamaria, J. A., & Yehuda, R. (2023). Reducing the harms of nonclinical psychedelics use through a peer-support telephone helpline. Psychedelic Medicine, 1(2), 69–73. https://doi.org/10.1089/psymed.2022.0017
Related workbook material
Qualifications and scope of practice: Criteria 2, 3, 4, and 27.
Consent and confidentiality: Criterion 28 and Core Functions II and III.
Client preferences and circumstances: Criterion 30.
Medical concerns and pharmacological safety: Criteria 1 and 2.
Client autonomy and decision making: Criterion 32.
Discussing the role of community: Criterion 35.
Evidence and application
Archer et al. reviewed structured collaborative care, which includes organized clinical treatment beyond ordinary referral work. The review provides context for communication and continuity across services; it did not test this workbook’s referral process.