Referral Intake Form

To make an immediate referral call 718-401-5700 or use this form

Referral Information

Patient Referral Client Referral Self Referral
First Name
Last Name
Gender	Male Female
Age
Phone Number
Homeless/Undomiciled	Yes No
Address Line 1
Address Line 2
City
State
Zip Code
Email Address
Referrer Contact Name
Referrer Contact Phone
Referrer Contact Relationship

Primary Doctor	No Primary Doctor
Have you ever been to our office before?	Yes No
HIV/Positive?	Positive Negative Unknown
Check special circumstances	UNDER 24 Years of Age Incarcerated Past 6 Months Homeless Recently in ER Other Special Circumstances:
Known illnesses	Other Illnesses:
Last time in Emergency Room
Mental health diagnosis	Other Mental Health Diagnosis:
Please check any immediate needs you have	Hepatitis C Test	HASA/PA Help
	HIV Test	Advocacy Groups
	Counseling	Adherence Help
	Medicaid	Medication
	SSI/SSD	Rent Assistance
	Legal Help	Emancipation Assist
	Detox	Drug Treatment
	Food/Pantry	Appointment Escort
	Income Assist	Housing Help/Eviction
	Other	Medical Care/Doctor

Medicaid Number:	No Medicaid Number
Other Insurance	None
Please indicate/describe in detail anything else about your health history that you think would be useful or important for us to know: