EMHOT Referral Form
Please provide as much information as possible while filing out this form
1. Date of Referral
*
/
Month
/
Day
Year
Date
2. Referred by
*
3. Referral Number
4. Consumer name
*
5. Date of Birth
*
-
Month
-
Day
Year
Date
6. Home number
Please enter a valid phone number.
7. Cell number
Please enter a valid phone number.
8. Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
9. Housing type
*
10. Are there other people living in the home
*
Yes
No
11. If yes, please provide details
12. Marital status
*
13. Primary Language
*
14. Is a translator needed?
*
Yes
No
15. Emergency Contact Information
*
16. Is the consumer aware of this referral?
*
Yes
No
17. Is the consumer an active PS Case?
*
Yes
No
18. Perceived Level of Risk
*
Low
Medium
High
19. Is there immediate risks or safety concerns?
*
Yes
No
20. Were emergency services called to mitigate immediate risks?
*
Yes
No
21. If yes, who?
22. Was consumer transported?
*
Yes
No
23. If yes, Where?
24. Behavioral Health Risk (reason for this referral)
*
25. Action steps completed? (i.e. made referral to PS, added to a counseling wait list, etc.)
*
26. Mental Health Diagnoses (confirmed / unconfirmed)
*
27. Medical Diagnosis
*
28. Medications
*
29. Family history of mental illness or behavioral health concerns? (Please provide details)
*
30. Weapons in the home?
*
Yes
No
31. Is the home hoarded?
*
Yes
No
32. Pest and/or rodent infestation?
*
Yes
No
33. Are there pets in the home?
*
Yes
No
34. If yes to any of these questions above, please provide details
Supports
35. Does the consumer have informal supports?
*
Yes
No
36. Name / Phone
37. Name / Phone
38. Name / Phone
39. Does consumer have formal supports?
*
Yes
No
40. If yes, which agencies are currently involved (please provide contact details)
Submit
Should be Empty: