REFERRING AGENCY INFORMATION Referring Agency Name:   Referred by: Phone Number: Address: Email: SERVICES REQUESTED : CLIENT INFORMATION Name: City: Address: Email: Phone: Cellular: Gender: Female Male SSN: D.O.B: Age: Source of Income: Monthly Amount: Food Stamps: No Yes Monthly Amount: Military Service: No Yes If yes, type of discharge: Parent/Guardian (if applicable):     Relationship: Phone: HISTORY OF HOMELESSNESS Current Living Conditions: How long: Length of Homelessness: How many times homeless in the past three years: MENTAL HEALTH HISTORY Mental Health Diagnosis:     Present Treatment for Mental Health (agency and location) with medications/dosage? Any Recent hospitalizations (within the past year): No Yes If yes, why? Doctor/Therapist's Name and Phone: DISABILITY HEALTH HISTORY Disability Health Diagnosis Disability Certification Statement will be faxed: No Yes Present Treatment for Disability (agency and location) with medications/dosage? Any Recent hospitalizations (within the past year): No Yes     Doctor/Therapist's Name and Phone: MEDICAL Applied for Medicaid: No Yes Accepted Denied Receiving Number Applied for SSI: No Yes Accepted Denied   Receiving Applied for SSDI: No Yes Accepted Denied   Receiving Insurance (Name of Provider):    Policy #: Name and Location of Primary Care Physician: Medical Condition (including allergies): Medications taken for any medical condition: Any recent hospitalizations (within the past year) No Yes If yes, please list date and reason : Smoke Cigarettes: No Yes SUBSTANCE ABUSE HISTORY How often does the client use alcohol?   How often does the client use other non-prescribed controlled substances?   Has there been use of a controlled substance within the past year? No Yes Unknown   Drug(s) of choice:   Present Treatment for Substance Abuse (agency and location):   Counselor:   Past Treatment (inpatient or outpatient) for substance abuse:   FORENSIC HISTORY Does client have any charges or convictions related to sex abuse? No Yes   Does client have any feloncy convictions? No Yes   Is client currently on probation or parole? No Yes   Has client ever been incarcerated for more than two (2) years? No Yes   Does client have any pending legal charges? No Yes   LIVING SKILLS Housing History and Patterns (Including timelines for homelessness if possible) Activities of Life (Hygiene, Housekeeping, Budgeting, etc.) Social Skills and Needs (Family Support, Social Functioning, Privacy Needs, etc.) Other comments or concerns       Attachments (optional) Most recent assessment : File: Most recent progress notes : File: Most recent diagnosis : File: Most recent treatment plan : File: Most recent pyschiatric/psyschological evaluation : File: Certification Statement I certify that this statement is true to the best of my knowledge and belief. I have attached (or faxed) all necessary documentation to support that the information provided is accurate. Signature: Name: Title: Phone: