+
Client Ethnicity *
Client Race *
Is the client pregnant? *
 
Is the client postpartum? *
Was the client recently released from jail/prison? *
Has the client been tested for HIV in the past 6 months? *
Has the client been tested for Hepatitis C Virus (HCV) in the last 6 months? *
Client diagnosis (check all that apply) *
 
Please check the service(s) you are referring this client to (Check all that apply--must select at least 1.) *
 
Does the client have an alcohol use disorder (AUD) diagnosis? *
Does the client have an opioid use disorder (OUD) diagnosis? *
Does the client have a methamphetamine use disorder? *
Does the client have any other substance use disorder (SUD) diagnosis? *
 
Does the patient receive Medication Assisted Treatment (MAT) for a substance use disorder of any kind? *
If the client receives MAT, has the client received MAT for 3 or more months without interruption? *
Powered byFormsite