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New Referral
FAQ
www.healthright360.org
Client's Basic Demographics
Referrer Information
Current Residency / Insurance Information
Recent Substance Use
Physical Health
Mental Health
Hospital Referral Form
Client’s Basic Demographics
Type of Referral
Clinic
Community / Street Outreach
Court
Hospital
Jail
Self / Family / Loved Ones
Legal Full Name of person being referred
*
Preferred Name of person being referred
*
Does person being referred have an SSN?
*
No
Yes
If yes, please enter SSN
*
Unmasked SSN
*
If no, please explain
*
Date of Birth
*
*
Sexual Orientation
Queer
Heterosexual
Bisexual
Gay
Lesbian
Questioning
Pansexual
Asexual
Other
Declined
Sexual Orientation Write In
*
Preferred Pronouns
Preferred Language
English
Spanish
Other
ASL
Amharic
Arabic
Armenian
Cambodian
Cantonese (Yue Chinese)
Chinese
Croatian
Farsi
French
French Creole
German
Greek
Gujarati
Hebrew
Hindi-Urdu (Hindustani)
Hmong
Hungarian
Ilocano (Iloko)
Indonesian
Italian
Japanese
Korean
Lao
Mandarin Chinese
Mien (lu Mien)
Mon-Khmer
Navajo
Panjabi (Punjabi)
Polish
Portuguese
Russian
Serbian
Sign language
Swahili
Tagalog
Telugu
Thai
Tonga
Ukrainian
Urdu
Vietnamese
Yiddish
Yoruba
Preferred Language - Write In
*
Phone number of person making the referral
*
Email of person making referral
*
*
Can we leave PHI (Personal Health Information) if unavailable?
No
Yes
Do you or your loved one struggle with substance use?
*
Is the person being referred a San Francisco resident?
No
Yes
Referral Status
Incomplete
New
Screening
Follow Up Needed
Pending Bed Schedule
Intake Scheduled
No Show
Arrived
Referral Closed
Assessment In Progress
Client Admitted
Not Cleared for Admission
Cleared for Admission
Screening Negative
SoMaRise
