Get Spring Street Shelter Referral Form - Mhasmc

The Spring Street Shelter Referral Form is an essential document for individuals seeking shelter assistance. This guide will provide you with clear, step-by-step instructions to complete the form online effectively.

Follow the steps to fill out the Spring Street Shelter Referral Form with ease.

1. Press the ‘Get Form’ button to access the referral form and open it in your preferred editor.
2. Begin by filling out the 'Client Name' field, ensuring you write the full name of the individual being referred.
3. Input the 'Referral Date' using the format __/__/__, reflecting the current date of completion.
4. Provide the 'Mental Health Number (MIS)' in the corresponding field to assist with identification.
5. Fill in the information for the 'Referring Person', including their name and phone number.
6. Indicate the 'Agency/Program' from which the referral is being made, ensuring clarity.
7. In the demographics section, complete the fields for 'Birth Date', 'Age', 'Social Security Number', 'Sex', 'Race', 'Primary Language', and 'Religious Preference' as applicable.
8. Enter the 'Client’s Current Address & #' accurately to ensure proper communication.
9. List the 'Next of Kin' along with their name, address, number, and relationship to the client.
10. Provide details about the 'Last Year of School Completed' and their 'Marital Status'.
11. Indicate the 'Legal Status' by checking the appropriate boxes provided.
12. If applicable, specify if there is a 'Restraining Order' in effect.
13. Detail any 'Legal Issues or current legal problems' the client may be experiencing.
14. Answer whether the client is a veteran and if they receive VA services.
15. List the diagnosis across the Axis categories (I, II, III, IV, V), providing specific information as needed.
16. Document any medications with their dosages in the specified fields.
17. Note the names of the prescribing medical professionals in the 'Prescribed by' section.
18. Outline the rehabilitation team, including names and phone numbers for all relevant contacts.
19. Summarize the 'Brief Psychiatric History', detailing hospitalizations and other pertinent information.
20. Describe the 'Presenting Psychiatric Symptoms', noting responses to medications and understanding of medication use.
21. Provide a description of social support and current activities in the respective sections.
22. Complete the 'Financial Information' section by accurately reflecting monthly income and sources.
23. Assess and document the client's life skills across various categories such as personal hygiene, handling money, and use of public transportation.
24. In the housing plan section, describe the future housing plan for the referred person.
25. Finally, gather signatures from the individual making the referral before submitting.

Complete and submit your Spring Street Shelter Referral Form online today.