Partner Referral Form

Patient Referral Form

For use by Community Agencies, Hospitals, and other organizations serving individuals in Houston.
Thank you for partnering with us to connect individuals to compassionate, comprehensive care.

This referral form is intended for use by community-based organizations, service providers, and case managers referring clients to Healthcare for the Homeless – Houston (HHH). Your responses help us route clients efficiently to the appropriate service team.

Please complete as much information as you are able. This form is not a substitute for new patient registration, but it allows us to begin outreach and triage quickly. If the individual is not already a patient, we will follow up directly to complete registration.

We will follow up on the referral within 24 - 36 hours. Please make sure to provide a phone number or email where we can reach the client or the person making the referral.

If you are a current or future patient, please click here to request an appointment instead of completing this form.
Referrer Information
Referring Agency Name*
Date of Referral*

MonthDayYear
Date
Referring Person Name*

First NameLast Name
Referring Person Title*
Referring Person Phone Number*
Please enter a phone number where you can be reliably reached.
Referring Person Email Address*
example@example.com
Reason for Referral

Please indicate the primary reason you are referring this client for services.
Primary Presenting Issue*

Medical CareMental Health CareSubstance Use / PsychiatryDental CareHIV/PrEP ServicesCancer Screenings / Preventive ServicesJail in-Reach / Re-Entry SupportProject Access Bus EnrollmentStreet Medicine Referral
Are there other services the client is interested in or might need?

Medical CareMental Health CareSubstance Use / PsychiatryDental CareHIV/PrEP ServicesCancer Screenings / Preventive ServicesProject Access Bus EnrollmentStreet Medicine Referral
Substance Use / Psychiatry Referral Details

These answers help us better understand the needs of the client and ensure they receive the most supportive and effective care possible.
Reason for Referral*

Medication assisted treatment inductionContinuation of buprenorphineRelapse supportMedication management onlyBehavioral health referralOther
Known Substance Use History

Opioids (heroin, fentanyl, prescription pain medication)Stimulants (cocaine, methamphetamine)AlcoholBenzodiazepines (Xanax, Klonopin, Ativan)CannabisHallucinogens (LSD, psilocybin, MDMA)Synthetic cannabinoids (K2, Spice)Unknown / UndisclosedOther
REACH Program Referral

Our REACH Program (Re-Entry Engagement and Community Health) is operated in partnership with the Harris County Sheriff's Office and provides continuity of medical and behavioral healthcare, housing support, and reentry planning for individuals exiting incarceration who are living with mental illness, substance use disorders, and homelessness.
Are you a member of the Harris County Sheriff's Office Reentry team?*

YesNo
Please note that at this time, we can only accept referrals from the Harris County Sheriff's Office for this program.
Client Information

This form is limited to reduce the amount of protected health information (PHI) transmitted.
Client Full Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Is the client aware of and agreeable to this referral?*

YesNo
SPN #*
Unit Housed*
Client Phone Number
If available, please enter a phone number where the client can be reliably reached.
Client Email
example@example.com
Preferred Contact Method(s)*

PhoneEmailThrough Referring Agency
Where did the client stay last night, to your knowledge?*
Additional Information
Is this person currently a patient at HHH?*

YesNoUnknown
Does the client already receive care at another clinic or hospital?*

YesNoUnknown
Where does this client typically receive care?*
What is the name of the client's current medical provider? (if known)
Please provide any additional information that would help us connect with the patient or coordinate care:
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Should be Empty:

Patient Referral Form

If you are a current or future patient, please click here to request an appointment instead of completing this form.

Referrer Information

Reason for Referral

Substance Use / Psychiatry Referral Details

REACH Program Referral

Please note that at this time, we can only accept referrals from the Harris County Sheriff's Office for this program.

Client Information

Additional Information