Referral Information
Referral type
*
Self referral
Agency referral
Family / friend referral
Other
Requested Services (select all that apply)
*
Native American transitional housing and SUD outpatient treatment (low intensity ASAM 1.0)
Native American SUD outpatient treatment only (low intensity ASAM 1.0)
Native American adult mental health targeted case management (AMH-TCM)
Native American outpatient mental health therapy (individual / group)
Other
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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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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