* = Required Information

Referral/MH/SA Screening Form

Multisystemic Therapy
Outpatient Therapy
Substance Abuse Intensive Outpatient Program
Intensive In-Home Services
To Be Determined
In Person
By Phone
By Fax
By E-mail
Other
Consumer is in crisis and needs immediate crisis intervention
Consumer is in danger of hurting himself/herself
Consumer is in danger of hurting others

Consumer Information

Male Female
Caucasian/White
AA/Black
Native American
Hispanic
Bi-Racial
Other
English
Spanish
Other
Single
Married
Divorced
Widow/Widower
Other

Number of Children

Medicaid
Health Choice
BCBS
Medicare
VR
IPRS
Other
Parent Legal Guardian Parent with Legal Custody (Please Submit Court Documents when Applicable)
Mark box if same as above
Mark box if same as above
Mark box if same as above
Mark box if same as above
Security code