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Referral Form
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1
REFERRAL FORM
All fields marked with
*
are required.
*
Legal Last Name:
*
Legal First Name:
*
Preferred/Chosen Name (if different than legal):
Social Security Number:
*
Date of Birth:
-Month-
January
February
March
April
May
June
July
August
September
October
November
December
-Day-
1
2
3
4
5
6
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24
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28
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31
-Day-
1
2
3
4
5
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10
11
12
13
14
15
16
17
18
19
20
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25
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29
30
-Day-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
-Year-
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
-Year-
2024
2020
2016
2012
2008
2004
2000
1996
1992
1988
1984
1980
1976
1972
1968
1964
1960
1956
1952
1948
1944
1940
1936
1932
1928
1924
1920
*
Age:
*
Sex:
Male
Female
Unknown
*
Is the patient a minor?
Yes
No
*
Home Address:
*
City:
*
ZIP:
*
Is Mailing Address different than Home Address?
Yes
No
*
Primary Phone #:
*
Alternate Phone #:
*
Ok to leave message?
Yes
No
*
What type of appointment reminder do you prefer? (Please select only one):
Text
Phone Call
None
*
Is Appointment Reminder Phone # different than Primary Phone #?
Yes
No
*
Primary Language at Home:
English
Hmong
Lao
Other
Spanish
*
Interpreter Needed?
No
Yes
*
Do you have a disability
Yes
No
*
Do you have an open Child Welfare Services (CWS) case?
Yes
No
*
List ages of children under age 15 in the home:
*
Are you currently a CalWORKs recipient?
Yes
No
*
Number in Household (on income)?
*
Are you a Veteran:
Yes
No
*
Insurance Coverage:
Medi-Cal
Medicare
None (Self-Pay)
Other
Private Insurance
*
Person Making the Referral:
Self
Parent/Legal Guardian
Other
*
Primary Drug/Alcohol Problem
*
Are you currently receiving services for drug and alcohol?
Yes
No
*
Are you currently pregnant?
Yes
No
*
Do you have a child aged 1 year or less?
Yes
No
*
Have you used alcohol or drugs in the past 30 days?
Yes
No
*
Have you used needles to inject drugs in the past 30 days?
Yes
No
*
In the past 12 months?
Yes
No
*
Have you been diagnosed with Tuberculosis?
Yes
No
*
1a) Have you ever had life-threatening symptoms during withdrawal?
Yes
No
*
1b) Are you currently having similar withdrawal symptoms?
Yes
No
*
2) Do you have any current, severe, and untreated physical health problems?
Yes
No
*
3) Do you feel that you are imminently in danger of harming yourself or someone else?
Yes
No
Yes to question 1a and 1b, and/or 3 requires the caller/client to immediately receive medical or psychiatric care.
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