Fields of Hope Referral Form
Client Information
First Name
Last Name
Phone
Email
Birth Date
Age
Are you completing this form for yourself, or someone else?
Myself
Someone Else
Name of Person Making Referral
Referrer Phone Number
Residence
Is client willing to enter our program?
Yes
No
Unknown
How did you learn about us?
Are you at risk of being homeless?
Yes
No
Unsure
If you are homeless, where did you sleep last night?
Current Living Situation
Car and/or Streets
Homeless
Homeless Shelter
In a Hotel
Own House/Apartment
Residential Treatment Program
With Friends/Family
Address
Have you previously been in a residential program?
Yes
No
If yes, please indicate the City,State and date range
City,State 2 digits for the month/ 4 digits for the year example: Billings,Mt 02/2023-06/2023
Social History
Do you have children?
Yes
No
Please list names and ages of children
Ever been arrested?
If yes, please explain
On probation or parole?
Are you currently affiliated with any gangs or live in a gang affiliated neighborhood?
Yes
No
Health History
Has client been diagnosed with any of these mental health disorders?
All
/
None
Anxiety Disorder
Bipolar Disorder
Depression
Dissociative Disorder
Attention Deficit Hyperactivity Disorder (ADHD)
Post-Traumatic Stress Disorder
Schizophrenia
Obsessive-Compulsive Disorder
OTHER - please explain
NONE
If OTHER Please Explain
Other (Describe)
Are you currently experiencing any symptoms from that diagnosis?
If Yes, Explain
Services Needed
Employment Assistance/Job Placement
Educational Support
Life Skills/Independence
Medical/Dental Assistance
Mental Health Services
Parenting skills
Other Assistance Needed
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