Referral Information
Referral type
*
Self referral
Agency referral
Family / friend referral
Other
Requested Services
*
Native American SUD treatment services with transitional housing
Mental health diagnostic assessment
Mental health targeted case management (AMH-TCM)
Mental health therapy
Health Education: Community Health Worker (CHW)
Substance use screening brief intervention and referral to treatment (SBIRT)
Other
Referral Contact
First Name
Last Name
Referral Phone Number
Please enter a valid phone number.
Referral Fax Number
Please enter a valid phone number.
Do you have a primary address
*
Yes
No, I am homeless
City the client is most often located
Referrals Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Language
Comments / reason for referral
Client Demographics
Form Submission Date
*
-
Month
-
Day
Year
Date
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
First Name
Last Name
Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
Social Security Number (SSN)
Sex at Birth
*
Please Select
Male
Female
Unknown
Current Gender Identity
Please Select
Not asked
Male
Female
Female to Male (FtM)/Trans Male/Man
Male to Female (MtF) Trans female/Woman
Genderqueer, neither exclusively male nor female
Additional gender category or other
Declined to Specify/ Chose not to Disclose
Race
*
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Declined to Specify
Other
Are you an enrolled tribal member?
*
Yes
No
Unsure
Which tribe are you enrolled with? (list one)
*
Are you a descendant of a tribe?
*
Yes
No
Unsure
Which tribe(s) are you a descendant of? (list all that apply)
*
Ethnicity
*
Not Hispanic or Latino
Hispanic or Latino
Both Hispanic and Non Hispanic
Declined to Specify
If known, specify ethnicity
mexican, columbian etc.
Client's Primary / Permanent Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Mailing Address if different from above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Cell Phone Number
Please enter a valid phone number.
Client's Home Phone Number
Please enter a valid phone number.
Client's Work Phone Number
Please enter a valid phone number.
Client's Email
example@example.com
Preferred Language
Client's Preferred Language
*
English
Spanish
Somali
Hmong
Other
Is an interpreter needed
Yes
No
Other
OLD Is an interpreter needed?
Yes
No
Other
Employment
*
Please Select
Not Employed
Full Time
Part-Time
Self-employed
Retired
Active Military
Unknown
Student
*
Please Select
Not a Student
Part-Time
Full-Time
Marital Status
*
Please Select
Single
Married
Separated
Divorced
Widowed
Partnered
Unknown
Do you have a guardian, or are you under the age of 18?
*
Yes
No
Parent / Guardian's Name
First Name
Last Name
Parent / Guardian's Phone Number
Please enter a valid phone number.
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Type of insurance (select all that apply)
Medicaid
Medicare
Commercial / Private
Uninsured
Other
If known, MA (PMI) Number
Insurance Company
Insurance Card (if available)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Photo ID Card (if available)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Can the client attend telehealth/virtual appointments?
*
Yes
No
Other
Person Completing Form
*
Client
Other
Person Completing Form Signature
*
Submit
Should be Empty: