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Referral Form

Reason For Services

Are you seeking services for (check all that apply):

Developmental Disability
Mental Health
Substance Use Disorder

Concerns

Concern 1

Concern 2

Choice 3

Drug/Alcohol Information:

Tobacco:

Alcohol:

Other Drugs:

Personal Information

Name

Date of Birth

Age

Address

Gender

Contact Phone

Contact Email

Best way to reach you

Contacts

Do you have a guardian?

Guardian Name

Guardian Phone

Are You Under 18?

If yes, please complete 1 and 2 below:

Mother’s Name:

Mother's Phone

Father’s Name:

Father's Phone

Who could we contact in case we are having a hard time connecting with you?

Name

Relationship

Phone

Living Arrangements

Who do you live with? (check all that apply)

Self
Roommate
Significant other
Spouse
Children
Parents
Siblings

Other:

Check all that apply:

Working FT/PT
Not Working
Seeking Employment
SSI
SSDI

Student:

Providers

Do you take medications?

Medication Name

Who is the prescriber?

Phone number?

Current Providers: Please list the name, clinic, and phone number for each provider.

Primary Doctor:

Psychiatrist:

Substance Use Counselor:

Mental Health:

Other Therapist

Other

Please check any you are currently involved with:

Social Services
Juvenile Justice
Child Protective Services
Adult Protective Services
Coordinated Services Team
Probation/Parole

Insurance(Name):

Insurance: check all that apply

MA
Medicare
Katie Beckett
None

Referent

If you are referring someone, please enter your information below.

Does the referred person know a referral has been made?

Name

Address

Phone

Signature

I understand that by submitting this form I will be contacted to further discuss my request for services to see if my needs can be met by The Human Service Center. Further I understand that if staff are not able to reach me directly, they have my permission to contact the person listed above as my contact.

I further understand that participation in any of these services is voluntary and requires a commitment. It will require attending appointments, completing any assignments, and completing documentation that is part of the service programs.

Signature Typing your name here means you accept the statement above.

Date

Please Answer: 2 + 4