Step
1
of
6
16%
SAP REFERRAL CHECKLIST
Completed Referral Forms
Yes
No
Client signed (ROI)
Yes
No
Presumed detox/MAT
Yes
No
N/A
2-sets of vitals (at least 1hr gap)
Yes
No
N/A
Date/Time
Set 1 - Date
Set 1 - Time
Set 2 - Date
Set 2 - Time
Have CIWA and COWS been completed
Yes
No
N/A
Proof of negative TB/PPD results attached
Yes
No
Physician Report/Physical
Yes
No
Proof of Insurance/Payment Arrangement Plan
(Required)
Yes
No
N/A
Type of Insurance
Med Order/PRN Order from Healthcare Provider
(Required)
Yes
No
N/A
CPAP Machine required
(Required)
Yes
No
N/A
Epi-Pen required
(Required)
Yes
No
N/A
Continuous Glucose Monitor required
(Required)
Yes
No
N/A
PARTICIPANT INFORMATION
Client Name
(Required)
First
Last
Participant ID#
(Required)
Participant Phone Number
Secondary Phone Number
DOB
(Required)
MM slash DD slash YYYY
Age
(Required)
Gender
(Required)
SS#
(Required)
Race
(Required)
Level of Education Completed
Religious Affiliation
Applicable
N/A
Next of Kin
Phone Number
Applicable
N/A
Emergency Contact
Phone Number
Applicable
N/A
Date of Arrival to Program
(Required)
MM slash DD slash YYYY
Referral Date
(Required)
MM slash DD slash YYYY
Referring Source
(Required)
Type of Admission
(Required)
New
Detox
Readmission
Other
Other
Provide information of last place of residency:
Facility/Program Name
Phone
Facility Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Or
Unknown
Homeless
Legal Status
(Required)
PC 290
AB109
Informal Probation
Formal Probation
CPS
Court
Parole
Unknown
N/A
Parole/Probation Officer
Phone
Through which County?
Employed
Yes
No
Last place of Employment
Date Last Employed
MM slash DD slash YYYY
Income Type
Amount
/per month
If other, please list (include county):
Staff Name
First
Last
Signature
(Required)
Date
MM slash DD slash YYYY
CLINICAL INFORMATION
Substance Use History
Yes
No
Unknown
Pre-Diagnosed Mental Health Conditiona
Yes
No
Unknown
Primary Diagnosis
Applicable?
N/A
Secondary Diagnosis
Applicable?
N/A
Substance Use History
(Required)
Yes
No
Unknown
If yes, explain
MEDICAL INFORMATION
Current physical medical conditions
Any open wounds/Known infections
(Required)
Treatment is required prior to the participant is admitted/
Yes
No
If yes, list
Any signs of incontinence/ need of incontinence products (adult diapers)
(Required)
Yes
No
If yes, list
Drugs of choice
Applicable?
N/A
Type
Smoke
Snort
Inject
Other
If other, please list
Date last used
Date of substance/alcohol used last.
MM slash DD slash YYYY
Unknown
Unknown
Length of use
Unknown
Unknown
Alcohol used in last 72 hours
(Required)
Yes
No
Unknown
If yes, does client have a history of blackout seizures
Yes
No
Unknown
Benzodiazepine used in last 72 hours
(Required)
Yes
No
N/A
If yes, does client have a history of blackout seizures
Yes
No
Unknown
Any opioid or narcotics used
(Required)
Yes
No
N/A
Your Information
Our Intake Team may need to contact you regarding this referral. Please include your information below.
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Referral submissions missing and/or documents will delay the intake process *** Pick-up Times TBD***
Digital File Upload
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 20 MB.
Here is the list of documents requested for upload.
Transitional Housing Referral Form
Medical Checklist or Physician’s Report (within 1 year)
List of all Current Medications (medical and psychiatric) – attach MARS
TB Skin Test or Chest X-Ray Clearance (must be within 1-year, same day testing applicable)
Medi-Cal Printout (if applicable) 6. ☐ Recent MD Progress notes (if applicable
Recent CM Progress Notes (if applicable)
If coming from a medical or psychiatric hospital, discharge summary
Most Recent Assessment (if applicable)
Recent Crisis Screening (if applicable)
Face Sheet (if applicable)
ROI
X
