USE THIS FORM ONLY FOR NON-EMERGENCY MENTAL HEALTH OR SUBSTANCE USE TREATMENT NEEDS
WE ARE NOT A HOUSING PROVIDER
REFERRING PERSON'S INFORMATION
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*
*
Yes
No
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REFERRAL INFORMATION ABOUT YOURSELF OR THE INDIVIDUAL WHO IS HOMELESS

STEP 1.


Yes
No

Yes
No
For individuals who are not homeless, refer to our Mental Health Provider Walk-in List or contact Managed Care Plan

Yes
No
If you answered Yes to A and B, proceed to Step 2

If you answered No to both A and B *STOP*

STEP 2.

For “Individual is currently connected to mental health and/or substance use treatment provider, and you have a question or are requesting a change.”
*STOP* This referral is for individuals who are homeless who are not connected to a Behavioral Health Service Provider. See Q&A #2

*

Yes
No
Unknown

Yes
No
Yes
No

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