Provider Referral Form

Provider Referral Form
Agency Info
Name of Organization: *
Contact/Referral Person: *

First Name Last Name
Referral Phone Number *

Area Code Phone Number
Contact/Referral email: *
example@example.com
Veteran Information
Veteran Being Referred *

First Name Last Name
Veteran Being Referred: *
Age *
Date of Birth *

Month Day Year
Date
Gender: *

Female Trans Female (MtF or Male to Female) Male Trans Male (FtM or Female to Male) Gender Non-Conforming (not exclusively male or female)
Branch of Service
Discharge Status
Veteran Phone Number (if applicable)

Area Code Phone Number
****Covid-19 Testing****

A "negative" Covid-19 test result is required within 24-48 hrs of entry
Test Results *

Negative Positive No Test
If tested, date of test

Month Day Year
Date Hour Minutes
Has the Veteran been out of state in the past 2 weeks?

Yes No
If Yes, what state did the Veteran come from, and when did they enter MA?
****Covid-19 Vaccination****
Has Veteran Received a Covid Vaccination? *

Yes No
Vaccine Manufactuer?
First Dose Date

Month Day Year
Date
Facility where you received 1st Vaccine?
Second Dose Date:

Month Day Year
Date
Facility where you received 2nd Vaccine?
Program Details
Is this referral for a specific program?

Yes No
If Yes, which program? *

Safe Haven WORTH GPD Clinical Treatment GPD Low Demand
If Yes, which program?*

Safe Haven WORTH GPD Clinical Treatment GPD Low Demand
*Please note specific programs may have additional screening and eligibility requirements, and indicating a specific program does not guarantee admission.
Housing History
Date of last permanent housing placement: *
Why is the Veteran currently experiencing homelessness: *
Where did the Veteran stay the most in the last 30 days? *
Where did the Veteran stay last night?
Medical Needs
Can the Veteran Manage Independently? (showering, medication administration, eating and bathroom hygiene) *

Yes No
If no, explain:
Does the Veteran have or need any medical breathing equipment such as a CPAP/BiPAP machine, or oxygen? *

Yes No
Does the Veteran use any medical supplies or continency products?: *

Yes No
If Yes, explain:
If Yes, what items?
Does the Veteran have any mobility issues, or utilize any mobility devices? *

Yes No
If Yes, please explain, and/or list the devices:
If Yes, Does Veteran Need Bottom Bunk/ Cot: *

Yes No
If Yes, explain:
If Yes, Can the Veteran Navigate Public Transit/ Walk in Community *

Yes No
Legal Barriers
Is Veteran a Sex Offender? *

Yes No
Level *
Parole/Probation? *

Yes No
Legal Issues/ Barriers to Housing
Additional Information
Should be Empty:

Provider Referral Form

Agency Info

Veteran Information

****Covid-19 Testing****

****Covid-19 Vaccination****

Program Details

*Please note specific programs may have additional screening and eligibility requirements, and indicating a specific program does not guarantee admission.

Housing History

Medical Needs

Legal Barriers

Covid-19 Testing

Covid-19 Vaccination