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Referrals

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Referral Information

First Name

Email Address

Last Name

Agency

Client Information

First Name

Last Name

Medical Assistance Number

Date of Birth

Social Security Number

Gender

Male

Female

Transgender

Unknown

Other

Telephone Number

Address

School/Grade

Parent or Legal Guardian Information

First Name

Address

Number of Dependents

Last Name

Telephone Number

Email

Please answer the following:

Is the consumer of Hispanic, Latino, or Spanish Origin?

Yes

No

Unavailable

Race

White

Asian

Black/African American

American Indian/Alaskan Native

Native Hawaiian

Other Pacific Islander

Not Availiable

How Well Does the Consumer Speak English?

Well

Not So Well

Not At All

Does the Consumer Speak Another Language at Home Besides English?

Yes

No

If yes, what language?

Number of Arrest in the Past 30 Days?

Number of Arrest in the Past 12 Months?

History

Medical Challenges

History of Mental Illness

Number of times in SUD Treatment

Cigarette Use

Yes

No

Known Physical Disabilities

Military Experience

Yes

No

Primary Source of Income

Employment

TCA

SSI

SSDI

Retirement

Other

None

Registered Sex Offender

Yes

No

Prescribed Medications

Primary Substance

Age of 1st Use

Date of Last Use

Total Years of Use

Length of Current Use:

1 month or less

1-6 months

6 months-1 year

1 year or more

Unknown

How often do you use?

How much do you spend?

Method of Use

Oral

Smoking

Inhalation

Injection

Withdrawal Symptoms

Longest Period of Abstinence

Secondary Substance

Age of 1st Use

Date of Last Use

Total Years of Use

Length of Current Use:

1 month or less

1-6 months

6 months-1 year

1 year or more

Unknown

How often do you use?

How much do you spend?

Method of Use

Oral

Smoking

Inhalation

Injection

Withdrawal Symptoms

Longest Period of Abstinence

Thanks for submitting!

Referral for Substance Use Disorder

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Referral Information

First Name

Email Address

Last Name

Agency

Client Information

First Name

Last Name

Medical Assistance Number

Date of Birth

Social Security Number

Gender

Male

Female

Transgender

Unknown

Other

Telephone Number

Address

School/Grade

Parent or Legal Guardian Information

First Name

Address

Number of Dependents

Last Name

Telephone Number

Email

Please answer the following:

Is the consumer of Hispanic, Latino, or Spanish Origin?

Yes

No

Unavailable

Race

White

Asian

Black/African American

American Indian/Alaskan Native

Native Hawaiian

Other Pacific Islander

Not Availiable

How Well Does the Consumer Speak English?

Well

Not So Well

Not At All

Does the Consumer Speak Another Language at Home Besides English?

Yes

No

If yes, what language?

Number of Arrest in the Past 30 Days?

Number of Arrest in the Past 12 Months?

History

Medical Challenges

History of Mental Illness

Number of times in SUD Treatment

Cigarette Use

Yes

No

Known Physical Disabilities

Military Experience

Yes

No

Primary Source of Income

Employment

TCA

SSI

SSDI

Retirement

Other

None

Registered Sex Offender

Yes

No

Prescribed Medications

Primary Substance

Age of 1st Use

Date of Last Use

Total Years of Use

Length of Current Use:

1 month or less

1-6 months

6 months-1 year

1 year or more

Unknown

How often do you use?

How much do you spend?

Method of Use

Oral

Smoking

Inhalation

Injection

Withdrawal Symptoms

Longest Period of Abstinence

Secondary Substance

Age of 1st Use

Date of Last Use

Total Years of Use

Length of Current Use:

1 month or less

1-6 months

6 months-1 year

1 year or more

Unknown

How often do you use?

How much do you spend?

Method of Use

Oral

Smoking

Inhalation

Injection

Withdrawal Symptoms

Longest Period of Abstinence

Tertiary Substance

Date of Last Use

Age of 1st Use

Total Years of Use

Length of Current Use:

1 month or less

1-6 months

6 months-1 year

1 year or more

Unknown

How often do you use?

How much do you spend?

Method of Use

Oral

Smoking

Inhalation

Injection

Withdrawal Symptoms

Longest Period of Abstinence

Areas of Supportive Need (Check all that apply):

Educational

Health Care

Legal

Primary Support

Housing

Social Environment

Occupational

Homeless

Unknown

Thanks for submitting!

1900 N. Howard St

Baltimore, MD 21219

HēL

Tel: 443-869-5393

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