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Referral Form
Please complete as much as possible to start the intake process. All information provided will be kept confidential. Please expect a call within 24-72 hours.
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* Indicates required question
Date
MM
/
DD
/
YYYY
Who is completing this form?
Self
Referral
Other:
Clear selection
If this is a referral, please share contact name and phone number
Your answer
Last Name
*
Your answer
First Name
*
Your answer
Age
Your answer
Cell Phone Number
*
Your answer
Where are you staying now?
Shelter
Family/Friends
Car
Hotel
Other:
Are you safe?
No
Yes
Other:
Clear selection
Have you reached out to Zelie's Home before?
Yes
No
Clear selection
Are you currently pregnant?
*
Yes
No
If yes, when are you due?
MM
/
DD
/
YYYY
Do you have other children in your custody?
Yes
No
Clear selection
If yes, please describe (how many children you have and how old they are)?
Your answer
Are you in danger? Is someone trying to harm you?
Yes
No
Other:
Clear selection
When was the last incident?
Your answer
Do you have a history of drug or alcohol use?
Yes
No
Clear selection
When was the last time you used drugs/and or alcohol? What is your substance of choice?
Your answer
Are you currently in a MAT program?
Yes
No
N/A
Clear selection
Are you aware of any warrants for your arrest?
Yes
No
Clear selection
Are you currently under the care of a mental health professional?
Yes
No
Other:
Do you have a mental health diagnosis? If so, please list medications prescribed
Your answer
What resources are you in need of?
Housing
Emergency Shelter
Clinic (healthcare assistance)
Food
Transportation
Other:
Please share specific time and dates for an intake interview within the next week?
Your answer
Notes
Please share any additional information you feel we should take into consideration.
Your answer
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