When is referral to another service appropriate, and how should it be documented?

• A. Never refer to other services.
• B. When needs exceed current resources or scope; document rationale, consent, referrals made, and follow-up plans.
• C. Only when the client asks for it.
• D. When the client has completed treatment.

Answer: (B)

When a client’s needs go beyond what you can provide or what your setting can offer, referral is appropriate. This reflects a commitment to connect the client with the right resources to support treatment goals, safety, and overall well-being, and it helps ensure continuity of care as issues may require specialized expertise or services outside your current scope.

Documentation should clearly capture the process: explain why a referral is needed (the rationale based on assessment of needs, resources, and scope), obtain and record the client’s consent to share information, list the referrals made (including provider names, contact information, and dates), and outline a follow-up plan (who is responsible, timelines for contact or check-ins, and expected outcomes). Include notes on any information that will be released and ensure confidentiality considerations are addressed. Align the referral with the treatment plan so progress can be monitored and coordinated across services.

Referencing scenarios where a referral isn’t appropriate helps illustrate why this choice fits best: refusing referrals ignores client needs; waiting only for client requests misses proactive planning and safety; and referring only after treatment ends neglects ongoing support during recovery.