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Please keep in mind that this is a working draft intended to support discussion and continuous improvement. The final template is expected to be adaptable for local implementation, including the addition of agency logos, branding, and other region-specific modifications. Thank you for sharing your expertise and helping develop a practical resource that will support coordinated intake and referral practices across California.

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As you review the draft, please consider the following questions:

Are there any fields or sections that should be added, removed, or revised?

Is the information requested clear, practical, and appropriate for coordinated referrals?

Are there any data elements that may create duplication or unnecessary burden?

Does the form support effective communication between referring and receiving agencies?

What additional recommendations would strengthen the template?

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Are these the questions you would expect staff or partner agencies to ask?

Are there additional questions that should be included?

Are the responses clear, practical, and easy to understand?

Are there any responses that should be revised or expanded?

What guidance would help support successful implementation of the referral process?