UConnectcare Referral Form

Referring Agency Or Individual *

Agency/Individual Contact *

Agency/Individual Contact Phone/Email *

Last Name of the Person Being Referred to UConnectCare (hereafter "participant") *

First Name of the Participant *

Middle Initial of the Participant

Participant Date of Birth * +

Participant Health Insurance Type

Participant Phone Number/Email (A working phone number is required. Also providing an active email address is highly recommended.) *

Participant Ethnicity *

Hispanic

Non-Hispanic

Unknown

Participant Race *

Is the Participant pregnant? *

No

Yes (Please provide due date if known.) Yes (Please provide due date if known.)

Is the Participant postpartum? *

Yes

No

Unknown

Was the Participant recently released from jail/prison? *

Yes

No

Unknown

Has the Participant been tested for HIV in the past 6 months? *

Yes

No

Unknown

Has the Participant been tested for Hepatitis C Virus (HCV) in the last 6 months? *

Yes

No

Don't known

Participant diagnosis (check all that apply) *

Please check the service(s) you are referring this Participant to (Check all that apply--must select at least 1.) *

Does the Participant have an alcohol use disorder (AUD) diagnosis? *

Yes

No

Unknown

Does the Participant have an opioid use disorder (OUD) diagnosis? *

Yes

No

Unknown

Does the Participant have a methamphetamine or psychostimulants use disorder? *

Yes

No

Unknown

Does the Participant have any other substance use disorder (SUD) diagnosis? *

No

Unknown

Yes (please specify) Yes (please specify)

Does the Participant receive Medication Assisted Treatment (MAT) for a substance use disorder of any kind? *

Yes

No

Unknown

If the Participant receives MAT, has the Participant received MAT for 3 or more months without interruption? *

Yes

No

Unknown