D.5 REFERRAL FORM

ATTACHMENT D.5- REFERRAL FORM

RFQ 36C24226Q0118

Emergency Housing Admission Referral
Please forward this referral along with
DD214 or Statement of Military Service to:
Scott Sussman
Fax (908)604- 5847
Phone (908)647-0180 X4425
Program Name:
Program Address:

Income Sources and Amounts:

Any pending benefit application and date submitted (e.g., Service Connection, Social Security):

ATTACHMENT D.5- REFERRAL FORM

RFQ 36C24226Q0118

Identifying Documents:  DD-214/Statement of Service (required)  Birth Certificate
 Award Letter

 Social Security Card
 Other:

Valid Driver’s License and/or CDL:  Yes

 No

Do you have a vehicle:

 Yes  No

Psychiatric Status and History (most recent diagnosis): Current Mental Health Treatment Provider(s):
History of suicide ideation/attempt (date and method; did it result in hospitalization)

Do you currently have the desire and/or means to harm yourself? History of thoughts to harm others or history of assault or violence: Substance Use History (substances, route of use, date of last use):

Triggers of substance use
Treatment History and date last attended treatment (detox/rehab/outpatient):

Medical Status and History (including adaptive devices):

Allergies:

ATTACHMENT D.5- REFERRAL FORM

RFQ 36C24226Q0118

Active Medications and Prescribing MD:
History of Abuse/Trauma:
Education
Additional School/Trainings/Skills :
Work History (last 2-3 jobs, dates of employment and type of work done):

Legal History (dates outcomes/pending warrants):

History of arrest (including assault, domestic abuse, Megan’s Law)

__

*Note: All fields are required. Falsifying information may disqualify you from eligibility of services.

ATTACHMENT D.5- REFERRAL FORM

RFQ 36C24226Q0118

Program Staff Use Only