Supporting the referral process

Criterion 46 follows a referral through the practical steps needed to reach care. The client may need help making contact, arranging an appointment, explaining the request, or dealing with cost and transport. Studies of medical referrals describe failures in communication and access, while a trial in opioid dependence illustrates the value of making effective treatment available promptly (Mehrotra et al., 2011; D'Onofrio et al., 2015). The facilitator works within an agreed role, checks what happened, and revises the plan when a barrier remains. Closure needs a documented status and a clear account of any continuing responsibility.

Learning Objectives

By the end of this module, the trainee will be able to:

• Distinguish a referral recommended, an appointment arranged, attendance confirmed, and a care need addressed.
• Describe the D'Onofrio et al. (2015) trial and explain why its findings cannot determine the effectiveness of every facilitated referral.
• Identify opportunities for timely care by qualified providers while maintaining the facilitator's own professional boundaries.
• Build an implementation intention with a client, in the if then form, and state the evidence for it and its limits.
• Ask about practical and personal barriers without assuming a universal order or attributing nonattendance to motivation.
• Review permission and the legal basis for sharing before contacting a receiving provider, as described in Criterion 45.
• Identify referral status accurately and establish when assistance ends or further coordination is needed.
• Treat non attendance as information about the referral and not as a verdict on the client.
• Recognize when continuing assistance requires a formally agreed care coordination or case management role.
• Track receipt of the referral packet, acceptance, outstanding information, and continuing responsibility.
• Transfer unfinished tasks and review delays and access failures.

Key Terms

Referral completion. Confirmation that the receiving service has engaged with the client and the responsibilities for the next step are understood. A single appointment may not resolve all of the needs that prompted referral.

Passive referral. The client is given a name, a number, or a list. Nothing further is done. The client is responsible for every subsequent step.

Facilitated referral. Assistance with reaching another service, which may include arranging contact, scheduling, sharing appropriate information, and confirming the next step. Its form and effectiveness vary by setting.

Referral status. What is known about contact, scheduling, attendance, acceptance, and continuing responsibility. Record the source of the information and leave uncertain outcomes identified as unknown.

Implementation intention. A plan that connects a chosen action with a specific situation or cue, often expressed as “If X occurs, I will do Y.” It can help make a next step more concrete (Gollwitzer and Sheeran, 2006).

Endpoint of assistance. The agreed point at which the facilitator's particular referral task ends, with a plan for remaining needs and any transfer of responsibility.

Non attendance. The client did not go. This is a finding about the referral, and the facilitator's first move is to ask what happened rather than to conclude what it means.

Privacy review before contact. Confirmation of the applicable permission or legal basis for sharing information, the intended recipient, the purpose, and the information required. General availability inquiries can often be made without identifying the client.

Core Teaching

Following the referral into care

Review the identified need, the client's understanding of the referral, the selected resource, and the arrangements for sharing information. Ask what help the person wants with the next step. They may be comfortable making a call independently or may want company while they do it. The amount of assistance should reflect their condition, preferences, urgency, and the program's agreed responsibilities.

Mehrotra et al. (2011) describe problems across the medical referral process, including decisions, information transfer, access, and communication back to the referring provider. A useful referral record therefore shows what has happened after the recommendation was made. Record whether contact was attempted, an appointment was offered, the client attended, and the receiving service accepted the relevant responsibility. A message sent to a provider does not establish that it was received or acted on (Patel et al., 2018).

Agree on how the referral's status will be checked and who will do it. This allows staff to identify an unanswered request or an inaccessible service while there is still time to change the plan.

Making timely care available

D’Onofrio et al. (2015) randomized 329 emergency department patients with opioid dependence to referral, brief intervention with facilitated referral, or initiation of buprenorphine with arranged primary care follow up. Treatment engagement at 30 days was 37%, 45%, and 78%, respectively. The facilitated referral comparison did not establish a statistically significant advantage over referral alone. The medication arm combined active treatment with organized follow up, so the trial cannot isolate the effect of referral assistance or predict results in psychedelic integration. A facilitator can arrange timely qualified care and evaluate the full route into that care within their role.

Plan the next step with the client and make clear what the facilitator can undertake within the service agreement.

Confirming an appointment is useful progress. Continue checking whether the client can attend and whether the service is appropriate to the need. If the outcome is unknown, record it as unknown and follow the agreed process.

Address barriers that fall within the team's role, including contact details, appointment instructions, transport information, interpretation, and the authorized transfer of relevant records. Where the person requires more sustained assistance, involve an appropriate coordinator or service.

Planning a specific action

An implementation intention links an anticipated situation with an action. It can help a client turn a general plan to seek support into a step they can recognize and carry out.

Ask when and where the client could make contact and what might interrupt the plan. For example, they may choose to call after breakfast on Tuesday, with the number already saved, and leave a message offering two suitable appointment times if nobody answers. Check that the time matches the service's opening hours and that the person has a private way to receive the reply. The plan should be realistic enough to revise if it does not work.

Gollwitzer and Sheeran (2006) reported an average effect of d = .65 across 94 tests of implementation intentions and goal attainment. The estimate concerns the varied studies in that review and should not be presented as the expected effect on this client's referral. This workbook uses the method as a practical planning aid; it does not claim that the review validates a psychedelic referral protocol.

Record the client's chosen action and the backup plan, then review what happened at the agreed time.

Finding out what prevents attendance

Ask what happened before attributing a missed appointment to reluctance. The person may have been unable to travel, afford the fee, find privacy, or understand the instructions. They may also have had concerns about the provider that were not apparent when the referral was made.

Review cost, coverage, waiting time, transport, work, childcare, language, disability access, technology, documentation requirements, and previous experiences with care. Their importance varies between people and settings. Ask which barrier is operating now and what would make the next step possible. If the client's symptoms are themselves preventing organization or attendance, obtain the appropriate clinical and practical support.

Explore ambivalence when the client describes it, while continuing to examine the service and access arrangements. A person can want care and still be unable to reach it.

Information sharing during assistance

Before contacting a receiving service, determine whether the inquiry needs to identify the client. General questions about availability, cost, or scope can often be asked without disclosure.

When a named referral is needed, explain what will be shared and establish the applicable permission or legal basis. Being a facilitation client does not itself establish that a person has used an unlawful substance; programs may provide preparation, education, lawful services, or support for past experiences. Nonetheless, identifying the relationship can disclose private information and requires care.

Follow the program's verified privacy process. Some disclosures require written authorization, while others may be permitted or required under the governing law. Confirm the recipient, use an approved channel, and share the relevant information. Emergency care should not be delayed while staff search for a routine release form when an applicable legal basis permits the needed disclosure (U.S. Department of Health and Human Services, n.d.-a, n.d.-b).

If a client wants to limit disclosure, discuss how missing information could affect the receiving clinician's assessment, including medication or substance interactions. Explore a narrower authorized summary or a conversation the client leads themselves. Obtain privacy or clinical guidance when a safety concern remains. Respect the client's choices within the applicable rules and explain any resulting limit on the service the program can provide.

Agreeing when assistance ends

Set the scope of referral assistance in advance, including contact methods, expected follow up, staff responsibility, and how care will transition if the need continues. Some programs have qualified case managers or care coordinators; others provide only limited assistance. The title alone does not determine what work is permissible. Review professional scope, competence, supervision, and the actual service agreement. Avoid informal arrangements that leave one staff member carrying open ended responsibility without support.

Use a status that accurately describes the referral and identify any outstanding action.

Completed: The client has engaged with the receiving service and the next contact or care responsibility is understood. Document who confirmed this and when.

Declined: The client has made an informed decision not to pursue the referral. Record the discussion, any continuing risk or unmet need, and what support or service limits remain.

Pending or reopened: Contact, access, or suitability remains unresolved. Record the barrier, the next action, and the person responsible for reviewing it.

Escalated: The person's condition or immediate risk requires a more urgent response. Activate the appropriate clinical or emergency pathway and document the transfer.

If the client cannot be reached, record the outcome as unknown and follow the agreed outreach and risk procedures. Closing an administrative task does not establish that the clinical need has been met.

Following the referral through its actual stages

Record the stages separately: resource identified, contact attempted, appointment offered, appointment accepted, attendance confirmed, and continuing responsibility established. A client may complete one stage and remain stuck at the next. Use “unknown” when there is no confirmation. This prevents a successful telephone call from being mistaken for care received.

Agree on how confirmation will occur and obtain the authority needed for any provider communication. The client may prefer to confirm attendance themselves. If the receiving service cannot share information, record that limitation instead of interpreting silence as refusal or failure. A referral can be closed administratively under a defined policy while its clinical outcome remains unknown; keep that distinction visible.

At each stage, assign the next action to a named person and give it a date. State who covers the task if that person is absent. An entry such as “follow up later” leaves the client dependent on memory. The record should show the action taken, the response, and any remaining concern.

A plan for the interval before care begins

Ask what support is available while the client waits. The answer may involve a qualified clinician, a different service, or a practical arrangement such as transport or a safe place to stay. State what the current program can provide and during which hours. A routine inbox should not be described as an emergency service.

Changes in symptoms may change the referral's urgency. Give the client clear instructions for obtaining urgent help and explain how to contact the program for ordinary questions. An emergency plan should not depend on a particular facilitator seeing a message immediately. When there is a current concern about safety, obtain appropriate assessment instead of treating the waiting period as an administrative problem.

Assistance without pressure

Offer the kind of help the client wants. Some prefer to call alone after rehearsing the conversation; others want a joint call. Check whether written instructions, an interpreter, transport assistance through an established service, or a different appointment time would help. Avoid turning support into repeated questioning after the person has clearly declined.

An implementation intention can make a chosen action more concrete: “After breakfast on Tuesday, I will call the clinic. If there is no answer, I will leave a message and try again Thursday.” Gollwitzer and Sheeran (2006) reviewed this planning method across general goal attainment studies. It is an option for referral planning, not a guarantee of attendance. The client should choose a feasible cue and an affordable contingency. Do not insist on a taxi the person cannot pay for or a private call their living circumstances do not allow.

Transport, financial aid, interpretation, and benefits assistance may be provided through legitimate programs by appropriately qualified staff. Define those services, eligibility, boundaries, and accountability. Informal personal loans, dependence on one facilitator's car, or open ended unpaid coordination can create difficulties that an established assistance service is better equipped to handle.

Missed contact and the end of assistance

Ask what happened before deciding why the client did not attend. The explanation may be cost, confusion, symptoms, an unsuitable provider, a changed preference, or several things together. Reassess urgency and revise the plan when appropriate. If contact is unsafe or the client has declined further outreach, follow the agreed limits and applicable duties.

Close the referral with a clear account of what is known, who now holds responsibility, and what remains unresolved. If more extensive coordination is needed, arrange an appropriate service within its actual professional requirements. Do not abruptly withdraw because assistance has become complex. Review program outcomes using consistent definitions and include unresolved referrals and missing information in the denominator. Attendance figures alone cannot establish that clients received suitable care.

Assigning the work across the referral

Use a referral log linked to the client's record. Each entry should identify the need, urgency, receiving service, permission or other authority for communication, current stage, next action, responsible person, and review date. Include coverage when the usual coordinator is absent. Keep access limited to the staff who need the information and avoid reproducing the full clinical history in a shared scheduling list.

Set a response process for overdue actions. A routine request can be checked with the practice; an urgent clinical need may require another route immediately. The log should make that difference visible. Staff should be able to identify which referrals are waiting on the receiving service, on missing records, on financial assistance, or on the client's decision. Each situation requires a different next step.

Preparing and confirming the referral packet

Agree on what the receiving provider needs and send it through the approved channel. Include the referral question, relevant history and findings, current medications with source and date, consent or disclosure authority as required, care already provided, and unresolved issues. Verify that every attachment belongs to the right person and that the recipient is correct. Keep a record of what was sent, to whom, when, and by which method.

Confirm receipt and whether the packet is sufficient for the requested decision. A fax confirmation or successful upload shows a transmission result; the practice still needs to review and act on it. Record any missing information, who will provide it, and the expected response. Tell the client when the next step changes, particularly if a delay affects travel, cost, or the availability of interim care.

When the receiving service declines

Ask for the reason within the applicable privacy arrangements. The problem may be scope, urgency, geography, insurance, a closed caseload, or missing information. Record the reason given and reconsider the next option with the client. If the need has become more urgent, obtain the appropriate clinical review. Avoid sending the same unsuitable referral repeatedly without addressing why it was declined.

Update the client on what has been tried and what remains available. A person who has retold their history several times may need help preparing a concise account and arranging the next contact. Respect the agreed limits on sharing, while explaining which information the next provider needs for a useful assessment. Keep the clinical need visible until it is addressed, transferred, declined with an informed plan, or documented as unresolved at the end of the program's involvement.

Transitions after emergency or inpatient care

When a client returns after emergency assessment or hospitalization, obtain the discharge plan through the appropriate process and clarify the program's role. Confirm medication and follow up questions with the responsible clinician. Record the condition at the latest contact, appointments arranged, activity or participation restrictions communicated by the clinician, and who will review a change.

The original referral may have led to several new tasks. Someone needs to confirm the next appointment, help with transport if agreed, and ensure that instructions reach the people carrying them out. A discharge document can arrive after the client has already returned home. Assign a reviewer so it is read promptly and consequential information is communicated to the client and responsible staff.

Ending or transferring coordination

Before coordination ends, give the client an accurate account of the current arrangements and any unfinished work. Identify the service that has accepted the next responsibility, the appointment or contact plan, and a route for urgent concerns. If the person declines further assistance, document the choice and any information provided about remaining needs. A staff member leaving employment should transfer open tasks to an identified colleague before access is removed.

Review referrals using defined stages and a complete denominator. Count the clients who needed referral, the stages reached, and the outcomes still unknown. Examine delays and access failures as well as completed appointments. Use the findings to change the process, such as checking eligibility earlier or arranging a backup service, and review whether that change reduced the problem.

Clinical and Decision Tools

Tool 1 Stages of a referral

Record the stage reached and the remaining action. Treatment initiation by a qualified provider depends on the clinical setting and authorization.

Tool 2 Barriers to reaching care

Tool 3 Implementation intention builder

Complete the plan in the client's own words and check whether the timing, contact method, and backup action are workable.

Tool 4 Privacy review before a referral contact

Tool 5 Referral status and continuing responsibility

Tool 6 Follow through checklist

Referral tracking entry

Worked Example Coordinating a Referral

This example follows a referral from the initial discussion through permission, practical arrangements, attendance, and confirmation of continuing care.

The situation

A client, four weeks after a psilocybin session, is describing panic that predates the session and that the session did not touch. The program is not a treatment provider and the facilitator is not a therapist. Criterion 42 identified the need. Criterion 43 named it plainly to the client. Criterion 44 matched it to a specific clinician who does exposure based work for panic and who takes the client's insurance, which the facilitator verified by calling the office before the client's name was ever mentioned.

Discussing cost and waiting time

The facilitator explains the verified fee, expected copay, and current wait, while noting that insurance benefits and appointment availability require confirmation. They ask whether these arrangements are manageable and whether the client wants to consider alternatives.

Checking barriers with the client

The client describes a long bus trip, work until six, and uncertainty about paying for several appointments. With permission, the facilitator checks evening availability and lower cost options. They discuss the expected ongoing cost before choosing an appointment.

Agreeing on information sharing

Before a routine joint call, the facilitator explains what information is needed for booking and obtains the applicable authorization. Relevant clinical information is discussed separately for an authorized handoff. The client is encouraged to provide an accurate medication and substance history to the treating clinician.

The call with the client in the room

The facilitator books the evening slot, confirms the copay with the office rather than assuming it, and hands the phone to the client so she hears the date from the person she will be seeing. The appointment card is written in her own handwriting.

The implementation intention

The facilitator asks how the client plans to reach the appointment and whether a cue or reminder would help. Together they check the date, route, timing, and a feasible alternative if the first plan fails.

The client chooses a reminder linked to leaving work on the appointment day. They identify the bus route and discuss what to do if it is delayed. A backup option is used only if it is affordable and acceptable to the client; otherwise they agree on how to contact the clinic and reschedule.

Agreeing on confirmation

They agree that the client will send a brief confirmation through a safe contact method. The facilitator explains when they will check for it and what follow up will occur if no response arrives.

Confirming continuing care

The client confirms attendance. The facilitator records the source of confirmation and the reported next appointment, checks any remaining coordination needs, and closes this referral task under the program's procedure.

Reviewing the cost barrier

Reviewing the example: The conversation identified a cost that could have interrupted continuing care. The referral record includes the arrangement reached and the date it should be reviewed. An initial attendance does not establish that later appointments will remain accessible.

Case Vignettes

For each vignette, identify the concern, describe the response, and explain your reasoning. Record your responses on a separate page.

Vignette A

A facilitator gives a client the names of three therapists and says any of them would be good. He does not know whether any is taking clients, what they charge, or whether they take her insurance. He records the referral as completed. Six months later he learns she never called anyone.

Guided questions: What was actually completed? Which resource and access checks were missing? How would you record the status and arrange the next action?

Vignette B

A facilitator makes a textbook warm handoff. She calls with the client present, books the appointment, transfers the notes, and confirms the date. She is satisfied and considers the matter closed. The client does not attend and the facilitator never learns this.

Guided questions: Which stage of the referral was completed, and which remained unknown? What can and cannot be inferred from the D'Onofrio trial? How would you arrange confirmation without overstating responsibility or invading privacy?

Vignette C

A facilitator calls a therapist and discloses a client's substance exposure and session details without checking the applicable basis for disclosure or the client's preferences. The information exceeds what was needed for the purpose of the call.

Guided questions: What was disclosed, and to whom, and by whose authority? Trace the reasoning back through Criterion 45. What is the difference between an unauthorized disclosure and a well intentioned one, from the client's perspective? What should the facilitator have said instead, and when?

Vignette D

A client misses two appointments. The facilitator begins driving her, then lends her the copay, then starts calling the clinic when she does not answer, then becomes the contact the clinic calls when she misses. Eight months later he is the only person holding her care together and he is exhausted and he cannot stop.

Guided questions: Which tasks were agreed, and how did the role expand? What assistance services or qualified coordination could meet the continuing need? How can responsibilities be transferred without abruptly leaving the client unsupported?

Vignette E

A client does not attend. The facilitator concludes she was not ready and closes the file. In fact her bus route changed, the new route takes ninety minutes, and she has a child to collect at six.

Guided questions: Ask the client what prevented attendance. Identify the access problem, revise the plan, and document what assistance will be provided.

Role Play and Practice Scripts

Practice with a partner or team, then exchange roles. Use fictional details and discuss the choices made in each response.

Naming the money and the wait before the referral

Practice explaining verified fees and availability, then asking whether the arrangement is workable over the likely course of care. Discuss uncertainty about benefits or future costs without presenting estimates as guarantees.

Exploring a concern about cost

The partner hesitates about cost. Ask once, respectfully, whether a lower cost option would help. Allow them to decide what they want to disclose. Practice offering assistance without repeated pressure.

The disclosure script

Explain the purpose, recipient, information, and authority for a proposed referral call. Practice obtaining any required authorization and discussing why accurate clinical information may be needed by the treating provider.

Building the if then plan

The partner says they plan to call this week. Offer to make the plan more specific. If they accept, agree on a cue, action, feasible contingency, and method of confirmation in their own words.

Asking what happened without a verdict

Practice asking what happened after a missed appointment, listening, and checking whether the explanation changes the plan or urgency. Avoid assuming either an access problem or ambivalence before hearing the person's account.

Asking after a missed appointment

The partner has decided not to attend. Check understanding of the recommendation and discuss relevant concerns within your role. Respect the decision, document it, and follow applicable safety duties and the agreed limits of further contact.

Additional Practice

Attendance remains unknown

An appointment was booked, but the client does not answer the agreed follow up. The receiving service cannot confirm attendance under the current authorization. The client previously limited voicemail messages.

Practice questions: Record the actual status. Describe permitted outreach, review of any safety concern, and the limits of administrative closure. Who holds the next task?

Applied Record Exercise

A packet sent without a response

A referral packet was transmitted last week. The receiving office says it is missing a report and has not reviewed the request. The original coordinator is leaving the program tomorrow.

Task: Update the actual stage, obtain the missing information through the proper process, transfer the open tasks, and give the client a clear next contact.

Review: The trainee confirms the barrier, assigns a reviewer and backup, checks urgency, and avoids recording the referral as completed.

Self Assessment and Reflection

Knowledge check

Distinguish a referral made from attendance confirmed and a receiving service's responsibility established.

Describe the population, intervention groups, and engagement findings in D'Onofrio et al. (2015).

Explain what the treatment package in that trial tells us and what a facilitator can apply within their role.

Create an implementation intention with a cue, action, feasible contingency, and confirmation plan.

Identify practical and personal barriers to referral use and explain how to establish which ones affect this client.

Explain how to establish the authority for routine information sharing and how urgent disclosures are handled.

Describe completed, declined, pending, escalated, and unknown referral status, including any remaining responsibilities.

Explain how to distinguish an unqualified substitute from appropriate interim care.

Reflection

Of your last ten referrals, how many outcomes were confirmed and how many remain unknown? What would improve that record?

When a client does not attend, what is your first private thought? Be honest about it, and then check it against the barrier inventory.

Where has your assistance expanded beyond its original agreement? What support or transfer of responsibility is needed?

How do you discuss fees and ongoing affordability? What would make that conversation clearer and more comfortable for the client?

Observed Practice Assessment

Use the unacknowledged referral packet exercise, then have the receiving service decline and the usual coordinator become unavailable.

The trainee confirms the actual referral stage, identifies why the request failed, reassesses urgency with appropriate input, and agrees on a feasible alternative with the client. Their log shows the packet status, communication authority, next action, date, owner, and covering colleague. Unknown outcomes remain visible.

Closing the referral as successful because a message was sent, coercing attendance, or ending coordination without addressing an unresolved urgent need requires revision and another observed handoff.

The assessor records the scenario, date, work reviewed, observed performance, feedback, and any required practice. Use the ratings demonstrated, needs further practice, or not observed for each task. A verbal answer alone cannot establish performance on a task requiring demonstration. Confirm readiness only for the work assessed and within the trainee’s authorized role.

Summary

Referral assistance follows the client’s progress from an identified option to the care actually received. Check suitability and access, offer practical help the person wants, establish authority for communication, and agree on a feasible next action. Record each stage separately and use unknown when confirmation is unavailable. Plan support during a wait and reassess when symptoms change. A missed appointment calls for inquiry and review of urgency. Close the task with clear continuing responsibilities, or arrange more extensive coordination when needed. Program review should include unresolved referrals and missing outcomes so apparent completion does not conceal gaps in care.

References

D’Onofrio, G., O’Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., Bernstein, S. L., & Fiellin, D. A. (2015). Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA, 313(16), 1636-1644. https://doi.org/10.1001/jama.2015.3474

Gollwitzer, P. M., & Sheeran, P. (2006). Implementation Intentions and Goal Achievement: A Meta‐analysis of Effects and Processes. Advances in Experimental Social Psychology, 38, 69-119. https://doi.org/10.1016/S0065-2601(06)38002-1

Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: Specialty referrals in the United States. Milbank Quarterly, 89(1), 39-68. https://doi.org/10.1111/j.1468-0009.2011.00619.x

Patel, M. P., Schettini, P., O’Leary, C. P., Bosworth, H. B., Anderson, J. B., & Shah, K. P. (2018). Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System. Journal of General Internal Medicine, 33(5), 715-721. https://doi.org/10.1007/s11606-018-4392-z

U.S. Department of Health and Human Services. (n.d.-a). Minimum necessary requirement. Retrieved September 18, 2026, from https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/minimum-necessary-requirement/index.html

U.S. Department of Health and Human Services. (n.d.-b). Summary of the HIPAA Privacy Rule. Retrieved September 18, 2026, from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html