Martin County HCHS Referral Form

New Horizons of the Treasure Coast, Inc.

Martin County’s Human Services Department (MCHS)

Referral Form

Last Name:

First Name:

MI:

Sex:

Social Security #:

Date of Birth*

Date

Age:

Address:

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Phone Numbers:

Emergency Contact:

Date of Referral:

Date

Referral Name:

First NameLast Name

Referral Source/Agency Affiliation:

Contact Phone Number:

Please enter a valid phone number.

Brief substance use history and current substance use concerns:

Is there a history of IV use:

Recent overdose(s):

Is the person pregnant:

Is there a history of substance use treatment:

(SU) Explain:

Does the individual have a mental health diagnosis:

(MH) Explain:

Does the individual have a history of mental health treatment:

(MHTx) Explain:

Is the individual currently taking and/or prescribed Suboxone:

Is the individual currently taking any medications:

If yes, please attach a legible copy of current medications, both routine and PRN, or list them below.

List Medications:

	Medication Name:	Dosage:	Prescribing MD:	Compliance (Y/N)
Medication
Medication
Medication
Medication
Medication
Medication

Please provide a brief medical history of the individual:

What is the individual's current medical status:

Does the individual have Medicaid or Medicare:

Third Party Insurance:

Insurance Company name:

Insurance Company phone #:

Please enter a valid phone number.

Is the individual indigent:

Staff Signature:

Date:

Date

MR #:

Demographic Information

Referral Information

Financial Status