Referral form

Community Transition Planning from Jail

Referral for Bridge Health

To be completed by a representative from the jail that is currently housing the individual
Individuals Information
Name

First NameLast Name
Birth Date*

MonthDayYear
Social Security Number*
Race:*

American Indian/Alaskan NativeAsian - OtherBlack/African AmericanMultiracialNative Hawaiian/Other Pacific IslanderOther Single RaceUnknown/Refused to AnswerWhite/Caucasian
Ethnicity:*

Hispanic/LatinoNon-Hispanic/LatinoUnknown/Refused
Gender:*

MaleFemale
Smoking Status:*

Smoker/Current Status UnknownFormer SmokerNever SmokerUnknown if ever smokedCurrent Every Day SmokerCurrent Some Day Smoker
Preferred Language:*

DeclinedEnglishFrenchGermanItalianMandarinOther LanguagePolishPortugueseSpanishTagalog
Referring Agency Information
Referring Agency Name*
Referring Agency Phone Number*
Referring Agency Representative*
County of Jail Referral:

CatoosaWalkerChattoogaDade
Should be Empty:

Community Transition Planning from Jail