Follow Up

Date of Referral

Name

Race

Date of Birth

SSN

Address

City

State

Zip Code

Phone Number

Email Address

Martial Status Martial StatusSingleMarried

Type of Insurance (Medicaid/Medicare/etc)

Insurance ID Number

Hospital or Incarceration Discharge Date

Name and Contact Info of referring Agency

Brief explanation of treatment needs (MH eval, SA eval, SA treatment, Psychiatric appt, medication, etc.)

Is individual currently on medications? If yes, please list

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