subject_line
Referring Agency
*
Agency Contact
*
Agency Contact Phone/Email
*
Last Name of the Person Being Referred to GCASA (hereafter "client")
*
First Name of the Client
*
Middle Initial of the Client
Client Date of Birth
*
+
Client Health Insurance Type
Client Phone Number/Email (A working phone number is required. Also providing an active email address is highly recommended.)
*
Client Ethnicity
*
Hispanic
Non-Hispanic
Unknown
Client Race
*
American Indian/Alaskan Native
Asian
Black or African America
Native Hawaiian or Pacific Islander
White
More than one race
Unknown
Is the client pregnant?
*
No
Yes (Please provide due date if known.)
Yes (Please provide due date if known.)
Is the client postpartum?
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Yes
No
Unknown
Was the client recently released from jail/prison?
*
Yes
No
Unknown
Has the client been tested for HIV in the past 6 months?
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Yes
No
Unknown
Has the client been tested for Hepatitis C Virus (HCV) in the last 6 months?
*
Yes
No
Don't known
Client diagnosis (check all that apply)
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Mental Health
Physical Disability
Mental Disability/Impairment
Emotional Disability/Impairment
None or Unknown
Other
Other
Please check the service(s) you are referring this client to (Check all that apply--must select at least 1.)
*
SUD Treatment
SUD Medication Assisted Treatment (MAT)
Psychostimulant support
Peer Support for Recovery from SUD
Parenting Peer Support
The Recovery Station (recovery center)
Support with Community Reentry from Jail/Prison
Case Management
Recovery Housing
Housing Assistance
Employment Assistance Services
Childcare Services
Transportation to Treatment
Prenatal/Postpartum Care
Other
Other
Does the client have an alcohol use disorder (AUD) diagnosis?
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Yes
No
Unknown
Does the client have an opioid use disorder (OUD) diagnosis?
*
Yes
No
Unknown
Does the client have a methamphetamine or psychostimulants use disorder?
*
Yes
No
Unknown
Does the client have any other substance use disorder (SUD) diagnosis?
*
No
Unknown
Yes (please specify)
Yes (please specify)
Does the patient receive Medication Assisted Treatment (MAT) for a substance use disorder of any kind?
*
Yes
No
Unknown
If the client receives MAT, has the client received MAT for 3 or more months without interruption?
*
Yes
No
Unknown
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