Date *

MM

DD

YYYY

Person Completing Referral *

First Name

Last Name

Name of Person Making this Referral (if different from the person completing this form) *

First Name

Last Name

Phone *

Referrals must include a valid phone number for contact.

(###)

###

####

Name of Person Being Referred *

First Name

Last Name

Phone *

Required for all referrals

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medicaid *

Yes

No

Other Insurance

Emergency Contact

First Name

Last Name

Emergency Contact Phone:

(###)

###

####

Date of Last Drug Use 1

MM

DD

YYYY

Date of Last Drug Use 2

MM

DD

YYYY

Date of Last Drug Use 3

MM

DD

YYYY

Current Legal Status:

Court Order

Probation

Parole

CPS

DUI

Does the individual have any illness compatible with COVID-19?

Check all that apply.

Fever

Cough

Shortness of Breath

Sore Throat

Runny Nose

Fatigue

Body Aches

Head Aches

Loss of Smell

Has the individual been in close contact with a sick person confirmed with COVID-19?

Check all that apply

Living in the same household as a sick person with COVID-19

Caring for a sick person with COVID-19

Being within six feet of a person with COVID-19

Being in direct contact with a person tested for COVID-19 with unknown results

Does the individual live or work with any of the following situations?

Check all that apply

Any setting where healthcare services are being delivered (hospital, behavioral health facilities, long-term care facilities, corrections, etc.)

Public safety occupation (law enforcement, firefighter, EMS, etc.)

Institutional or congregate setting (corrections, shelters, etc.)

Critical infrastructure occupation (grocery stores, pharmacist, gas station, public utilities, etc.)

Ability to Perform Activities of Daily Living?

Yes

No

Need Handicap Accessible Accomodation?

Yes

No

Pregnant?

Pregnant

Post-Partum (Baby is 12 months or younger)

N/A

Post-partum?

Yes

No

N/A

Do you have a child under the age of 1 year that you would like to bring to the facility?

*** This Question Required for Turning Pointe ONLY ***

Yes

No

N/A