Eligibility for LEAD:
Name
First Name
Middle Name
Last Name
Suffix
Nickname
Closest contact
Name and Phone Number or Address
Date of Birth
Month/Day/Year
Social Security # last 4 digits
Race/Ethnicity
Asian
Black
Hispanic
Native American
White
Multi-racial
Other
Gender
Female
Male
Transgender FTM
Transgender MTF
Non-binary
Other
Phone Number
Voicemail:
Yes
No
Email address
Street Address
Where can LEAD staff locate you?
Where did you sleep last night?
Do you have a job?
Yes
No
Where do you work?
Case Manager Present at Diversion?
Yes
No
Assigned Case Manager
Date referral received by HRDA
/
Month
/
Day
Year
Date
Notes:
Referral Agency
LEAD Eligibility Check
Are you under 18 years old?
Are you currently participating in an adult drug court program?
Have you been convicted of a violent crime in the past 5 years?
Individual agrees to sign a Consent Form so LEAD staff can coordinate their care.
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