AGS Programs
SUD Referral
Returning Consumer:
Yes
No
Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
mm/dd/yyyy
Consumer Name:
DOB:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
mm/dd/yyyy
SSN#:
MA#:
Gender Assigned at Birth:
Gender Identity:
Sexual Orientation:
Phone Number:
(999) 999-9999
Format: (000) 000-0000.
Message OK?
---
Yes
No
Email Address:
example@example.com
Living Situation:
Mailing Address:
Street
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
School/Grade (if applicable):
Address of School:
Preferred Method of Contact:
---
Phone
Text
Email
Best Time to Call:
Are you Employed?
---
Yes
No
If yes, (select type)
Supportive Employment
PT
FT
Referral Source Information
Name:
Agency (if applicable):
Phone Number:
(999) 999-9999
Format: (000) 000-0000.
Fax Number:
Email Address:
example@example.com
Relationship to Consumer:
Parent/Guardian Information
*A LEGAL DOCUMENT MUST BE PRESENTED TO SHOW GUARDIANSHIP - COURT ORDER/LEGAL DOCUMENTATION*
Name of Parent/Guardian:
Relationship:
Address:
Contact Number:
(999) 999-9999
Format: (000) 000-0000.
Please answer the following
Is the consumer of Hispanic, Latino, or Spanish origin?
*
---
Yes
No
Unavailable
Race:
*
---
White
Asian
Black/African American
American Indian/Alaskan Native
Native Hawaiian
Other Pacific Islander
Not Available
How well does the consumer speak English?
*
---
Well
Not so well
Not at all
Does the consumer speak another language other than English at home?
*
---
Yes
No
If Yes, what is the language?
---
Spanish
French
Arabic
Greek
Other
Number of arrests in the past 30 days?
*
---
None
1-99
Is the consumer deaf or do they have hearing difficulty?
*
---
Yes
No
Unknown
Is the consumer blind or do they have serious difficulty seeing, even when they wear glasses?
*
---
Yes
No
Unknown
Reason for Referral/Primary Concerns:
SUBSTANCES USE:
Rows
Type of Substance
Age at First Use
Route of
Transmission
Frequency of Use
Date of Last
Use
1
2
3
4
5
Currently Receiving Medication Assisted Treatment?
*
Yes
No
Clinic Name/Phone Number of MAT:
Mental Health Diagnosis:
Current Therapy/Treatment Supports:
Electronic Signature: (Please type Full Name & License credentials)
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
mm/dd/yyyy
Electronic Signature Agreement:
*
I agree and understand that checking this box constitutes an electronic signature.
Please verify that you are human
*
Submit
Should be Empty: