Martin County HCHS Referral Form

New Horizons of the Treasure Coast, Inc.

Martin County’s Human Services Department (MCHS)

Referral Form

Please complete the entire form. If any information is unknown to you, please specify unknown.

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

FOR OFFICE USE ONLY