Seniors and Hispanic Outreach Referral Form

    If you would like to refer someone to our program, please fill out our form below.

    * Indicates a required field

    Primary Language Spoken *
    If Other Language
    Name *
    Client Information
    Date *
    Address *
    City *
    State *
    Zip Code
    Phone Number *
    Date of Birth *
    Age *
    Ethnicity
    Ethnicity if Other
    Gender *
    Contact Name
    Emergency Contact Information
    Relationship
    Contact Phone Number 1
    Contact Phone Number 2
    Referral Name *
    Referral Source (individual completing this form)
    E-mail Address *
    Relationship to client
    Agency
    Referral Phone Number
    Is client aware of the referral?
    Should the referral source accompany client on initial visit?
    Presenting Problem
    Reason for Referral/ Goal
    Past/current mental health treatment
    (including hospitalization, outpatient treatment, etc.)
    Significant health Problems/ medications
    (list medications)
    Does the client see a therapist/psychiatrist?
    Provider Name
    Provider Phone Number
    Is client able to attend office appointments?
    If 'no' please explain:
    Does client have a primary care physician?
    PCP Name
    If 'yes'
    PCP Phone Number
    Is client being followed by DHHS staff?
    Staff Name
    If 'yes'
    Staff Phone Number
    Other agencies involved with the client (list)
    History of the following
    Current substance abuse/treatment? *
    Suicide attempts? *
    History of violent behavior? *
    Weapons in the house? *
    Pets in house? *
    Please describe pet(s) if 'yes'
    Active bedbug infestation within the last year? *
    Additional Information
    Attachments
    Attach supporting documents here.
    Image Verification *
    Please type the phrase above into the box below