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DATE: PERSON MAKING REFERRAL: REFERRAL SOURCE ADDRESS: PHONE: RELATIONSHIP TO INDIVIDUAL: IS THE INDIVIDUAL AWARE OF THE REFERRAL? ?YES/ ?NO WHY NOT?FIRST: MIDDLE: LAST:DATE OF BIRTH: SSN:GENDER: ?Male ?FemalePHONE: / Place to Leave Messages:ADDRESS:CITY:STATE: COUNTY:LEGALLY RESPONSIBLE PERSON: RELATIONSHIP:PHONE: ADDRESS:CITY:STATE: COUNTY:REASON FOR REFERRAL:ARE YOU CURRENTLY RECEIVING SERVICES? ? NO / ? YES: TYPE OF SERVICES:PROVIDER NAME: PHONE:PROVIDER ADDRESS:MEDICAID ID: MEDICARE ID:MCO ID: OTHER INSURANCE:PRIMARY CARE PHYSICIAN: PHONE:ADDRESS: CITY/STATE: I. Race: ?White ?Black ?American Indian / Alaskan Native ?Asian / Pacific Islander ?Biracial ?Other: _______________________ II. Ethnicity: ?Not Hispanic Origin ?Hispanic, Mexican American ?Hispanic, Puerto Rican ?Hispanic, Cuban ? Hispanic, Other III. Marital Status: ?Single ?Married ?Separated ?Divorced ?Widowed ?Domestic PartnersEmployment Status (check only one) ?Unemployed ?Employed full-time ?Employed part-time ?Disabled V. Veterans Status: ? Yes ? No VI. Highest Grade Completed: _____ Current Grade: _____Current School: ____________________________________VII. Living Arrangements (Check only one): ? Private residence ? Rooming House ?Homeless ?Correctional facility ?Institution ?Residential facility ? Foster family or alternative family ?OtherVIII. Legal Competency Status: ?Minor ?Competent ?Incompetent (attach documentation of adjudication)Individual Completing Form: Date: ................
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