referral document

Referring Document
Name Of referring agency*
Name of whom is filling out this document*
Email(person filling out the document)*
example@example.com
Phone Number*
Please enter a valid phone number.
type of agency(referring)*
Date-today*

MonthDayYear
Date
Hour MinutesAM/PM Option
Name-participant*

First NameLast Name
Email of participant(looking to receive services if different from above)
example@example.com
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preference of communication*
Best time to communicate*
Gender*
- **Phone Number**
Race ethnicity*
Age*
Email
example@example.com
Insurance*
If Medicaid, please provide your Health first Colorado/ CHP ID number/state ID number
Available on: members card, letters(benefits), mobile app, call(1-800-221-3943; 711
Physical ailments(that prevent you from working/volunteering/ fitness
If yes please explain
Do you have any mental health concerns you need support with
If yes please explain
### 4. Religion & Marital Status
Religion(optional)
Martial status*
Substance Use-drug history*
On a scale of 0-5 for (0 none, 1 being low drug use- 3 being moderate- 5 daily)*
Substance Use-Alcohol history*
On a scale of 0-5 for (0 none, 1 being low alcohol use- 3 being moderate- 5 daily)*
Employment status*
if self employed, what is your business industry type and company name
Are you looking for work and are you ready to work?*
Do you receive SNAP/Food stamps*
Do you receive TANF*
Custody status*
Current living situation*
Criminal history(choose all that apply)*

FelonyMisdemeanorNone
Gang involvement*

Yes(active)Yes(not active)Never
Do you have Children*
If yes, how many
parental custody*
Hobbies and interests*

AthleticsFitnessPartyingDrinking AlcoholUsing DrugsReadingHikingCooking TypeMusicDrivingGardeningSwimmingCampingDrawingCleaningFarmingPetsArtsVideo gamingMovies
Check all that apply (if you have….)*

IEP504 learning planMental health concerns/diagnosesAnger issuesHealth concerns(physical)Gang involvementSNAP/food stampsTANFMedicaidMedicareCriminal historyI don’t have any of theseLearning disorder/concernsBehavioral health concerns
Education(last grade completed)*
Trades school*
Goals(choose up to 6, minimum of 3)*

Get a JobMentorship/life coachingGet a raiseStable housingComplete RehabSobrietyEnroll in RehabGet LicenseComplete Job training/EducationGEDComplete certificationEnroll in therapyComplete Supervision(probation/parole)Tattoo removalSign-up for benefits(medicaid/food stamps/SNAP)ClothingFitness(Healthy)Marriage/RelationshipGet/receive medicationPhysical TherapyTransportationParenting(involvement)Anger ManagmentPart-time employmentEntrepreneurship(start a business)Computer Skillshigh school diplomaQuick smoking cigarettesReduce substance abuse
Triggers(pick your main one 1)*
what influences my negative behavior
Triggers manifested
when triggered what happens next?
Which staff are you working with(at CAA and WHealthy)(Choose one)*
whom do you want this referral to go to
Comments or additional information
Should be Empty:

Referring Document