Referral Information
Referral type
*
Self referral
Agency referral
Family / friend referral
Other
Requested Services
*
Native American Assessments and Referral (SUD Comprehensive Assessment / Mental Health Diagnostic Assessment)
Native American SUD outpatient treatment
Native American adult mental health targeted case management (AMH-TCM)
Person Making Referral
First Name
Last Name
Referring Agency Name
Person Making Referral Email
example@example.com
Person Making Referral Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Person Making Referral Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Person Making Referral address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What city the client is most often located
Reason for Referral / Comment
Client Demographics
Form Submission Date
*
-
Month
-
Day
Year
Date
Client's Legal Name
*
First Name
Middle Name
Last Name
Client's 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
Enrolled tribal member?
*
Yes
No
Unsure
Enrolled with which Tribe? (list one)
*
Are you also a descendant of another tribe(s)?
Yes
No
Unsure
Descendant of a Tribe(s)?
*
Yes
No
Unsure
Descendant of which Tribe(s) (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.
Current housing status
*
Homeless: shelter or couch hopping
Homeless: streets or encampment
Transitional / temporary housing
Permanent housing
Other
Client's Primary / Permanent Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a mailing address?
Yes
No
Client's Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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
Unknown
Marital Status
*
Please Select
Single
Married
Separated
Divorced
Widowed
Partnered
Unknown
Has a guardian, or is 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.
Format: (000) 000-0000.
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of insurance (select all that apply)
Medicaid
Medicare
Commercial / Private
Uninsured
Other
If known, MA (PMI) Number
Insurance Company Name
Insurance Card (if available)
Browse Files
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of
Photo ID (if available)
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of
Can attend telehealth/virtual appointments?
Yes
No
Other
Person Completing Form
*
Client
Other
Person Completing Form Signature
*
Submit
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