Consumer Referral/Intake Form

Consumer Referral/Intake Form

Please fill out the following form to refer yourself or a consumer. All information provided will be handled in strict compliance with HIPAA regulations to ensure consumer's confidentiality and data security.
Consumer Full Name*

First NameLast Name
Enter Consumers Email Address*
example@example.com
Date of Referral*

MonthDayYear
Date
Enter Consumer's Home Address*

Street Address

Street Address Line 2
CityStateZip Code
Enter Consumer's Mobile Phone Number (Enter 999-999-9999 if no Mobile Phone)*
Please enter a valid phone number.
Enter Consumer's Home Phone Number (Enter 999-999-9999 if no Home Phone)*
Please enter a valid phone number.
Enter Consumer's Date of Birth*

MonthDayYear
Date
Choose Consumer's Highest Level of Education*
Choose one answer
If Middle School or High School, what is the last grade completed by Consumer?
Choose Consumer's Marital Status*

SingleMarriedSeparatedDivorced
Name of the Last School Attended by Consumer
Consumer's Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherPrefer not to answer
Consumer's Gender*

WomanManNon-BinaryTransgenderOtherPrefer not to answer
Consumer's Sexual Orientation*

Heterosexual (Straight): Attraction to people of the opposite sex/genderHomosexual (Gay/Lesbian): Attraction to people of the same sex/gender (Gay for men/general, Lesbian for women)Bisexual: (Attraction to people of more than one gender, not necessarily equallyAsexual: Experiencing little or no sexual attraction to any gender; different from celibacyPansexual: Attraction to people regardless of their genderDemisexual: Experiencing sexual attraction only after forming a strong emotional bond
Upload Images for Consumer's Insurance Cards (including Medicaid) and Social Security Card

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Consumer's Medicaid Number*
Ex., 999888777X
Consumer's Social Security Number*
Ex., 555-99-3333
Consumer's Emergency Contact Full Name*

First NameLast Name
Consumer's Emergency Contact Address*

Street Address

Street Address Line 2
CityStateZip Code
Consumer's Emergency Contact Phone/Mobile Number*
Please enter a valid phone number.
Consumer's Primary Care Doctor's Full Name (if no doctor type No Doctor)*

First NameLast Name
Consumer's Primary Care Doctor's Location/Address (if no doctor type No Doctor)*

Street Address

Street Address Line 2
CityStateZip Code
Enter Consumer's Weight*
Ex., 198 pounds
Enter Consumer's Height*
Ex., 5 feet 8 inches
Choose Consumer's Natural Eye Color*

BlackBrownBlueGreenOther
Choose Consumer's Natural Hair Color*

BlackBrownBlondGreyRedBaldOther
Choose Consumer's Vision Status (check all that apply)*

Normal VisionNo Corrective LensesSome Difficulty SeeingNeeds GlassesWears GlassesUndeterminedLegally Blind
Choose Consumer's Hearing Status (check all that apply)*

Normal HearingNo Hearing AidMild Hearing LossModerate Hearing LossProfound Hearing Loss (Deaf)Wears Hearing AidUndetermined
Choose Consumer's Dental Status (check all that apply)*

Good Dental HealthNeeds Dental ServicesUndetermined
Choose Consumer's Speech Status (check all that apply)*

No Speech ImpairmentMild Speech ImpairmentModerate Speech ImpairmentProfound Speech ImpairmentNeeds Speech TherapyUndetermined
List Any Allergies the Consumer Has*
List the Consumer's Current Medications*
List Any Medical/Mental Health Diagnoses the Consumer Has*
List Any Consumer Family Medical History of Illnesses/Diagnoses*
Ex., My Mother has diabetes
Describe Consumer's Family Relationship(s) and Relationships w/Others*
Describe Consumer's Social Interaction w/Others*
Describe any Physical Abuse Experiences of Consumer*
Describe any Experiences of Neglect or Abandonment of Consumer*
Describe any Current and/or Past Use of Substances and List Substances Used by Consumer*
Describe Consumer's Spiritual Beliefs*
Describe Consumer's Individualized Strengths (any family, social, spiritual support, hobbies, and attitudes that have helped them to recover from past crises)*
Describe Consumer's Individualized Needs (any current needs emotionally, physically, socially, and/or environmentally)*
Describe Any Current and/or Past Legal Issues of Consumer*
Check any applicable Advance Directives for Consumer*

Living Will: Details your preferences for life-sustaining treatments (like ventilators or feeding tubes) if you're terminally ill or permanently unconscious.Durable Power of Attorney for Health Care (or Health Care Proxy/Agent): Appoints a trusted person (agent) to make medical decisions on your behalf if you can't.Do Not Resuscitate (DNR) Order: A specific medical order to not perform CPR if your heart or breathing stops.POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment): A doctor-signed medical order for seriously ill patients that translates preferences into actionable orders, used across different care settings:No Advance Directives
Programs Requested (check all that apply)*

Substance Abuse Intensive Outpatient (SAIOP)Comprehensive Substance Abuse Treatment (SACOT)Outpatient TherapyContinuing Care SupportRelapse Prevention
Services Requested (check all that apply)*

Individual CounselingFamily CounselingMarriage CounselingAddiction CounselingGrief CounselingCase Management/Care CoordinationEvidence-based Group TherapyPeer SupportRecovery Coaching
Reason for Consumer Referral (check all that apply)*

Self ReferralReferred by SomeoneLegal (Court, Probation, Parole, etc.)Treatment Accountability for Safer Communities (TASC)Other
If Referred by Someone, Enter the Name of the Person Who Referred You

First NameLast Name
If Referred by Someone, Enter the Email of the Person Who Referred You
example@example.com
If Referred by Someone, Enter the Phone Number of the Person Who Referred You
Please enter a valid phone number.
Enter the Place of Who Referred You
Example: Varick on 7th
Patient Data Privacy and Confidentiality Agreement*

I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations as permitted by HIPAA.I understand that my information will be handled securely and in compliance with HIPAA regulations.
Provider Data Privacy and Confidentiality Agreement*

I confirm that the healthcare providers involved will handle the patient information in compliance with HIPAA.I acknowledge that all data will be stored and transmitted securely to protect patient confidentiality.
I agree to the terms and conditions regarding data privacy and HIPAA compliance.*
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