Latino CART Referral
Medical Criteria
Is the person requesting Latino CART services a resident of the city of Chelsea?
Yes
No
Is the person requesting Latino CART services uninsured or underinsured?
Yes
No
Uninsured
Underinsured
Is the person requesting Latino CART services experiencing emotional/behavioral health issues that are affecting the person’s normal functioning in any life domains?
Yes
No
School
Family
Physical Health
Emotional Health
Community
Work
Other
Latino CART services
Referral Date:
-
Month
-
Day
Year
Name:
HUB #:
(If Not HUB, add 0)
Date Of Birth:
-
Month
-
Day
Year
Type a question
Male
Female
Other
Address:
Phone Number:
Referred by:
(add SELF, if self-referral)
Agency Name:
Phone:
List current risk factors:
Homelessness
Housing Stability
Newly Arrived Immigrant
Domestic Violence
Substance Use
Current/Active Deportation
Lack of Meaningful Activities
Unstable Emotional/Mental Health
Lack of Basic Needs
Lack of Stable Employment
Lack of School Attendance
Disabled
Unstable Emotional/Mental Health
No Social Connections
No Natural Supports
Breakdown in Family Relationship
Other
Suggested Goals
1.
2.
3.
Submit
Should be Empty: