Client's First Name: *

Client's Last Name: *

Client's Date of Birth:

Client's Age: *

What is the individuals primary residence? * Please select one Independent Home with Parents With Relatives With Non-Relatives With Significant Other With Friend Foster Care Group Home Residential Detention/ Jail Psychiatric Hospital Homeless Other

Other (please specify) *

Is the client a resident of Fort Bend County? * Please select one Yes No Unknown

Client's Phone Number: *

Legal Guardian Phone Number (if applicable):

Race *

Ethnicity * Please select one Hispanic/Latino Non-Hispanic/ Non-Latino

Insurance Status (check all that apply) *

Probation/ Parole Status (if applicable) Please select one Pre-trial Deferred Probation Pending Temporary Pre-Court Conditions Saved By The Bell Other

Other (please specify) *

Involved in Specialty Court? (if applicable) Please select one Pre-trial Mental Health Court: Misdemeanor Mental Health Court: Felony Infant Toddler or Cluster Court Other

Other (please specify) *

Is there a Mental Health Diagnosis * Please select one Yes Suspected Unknown No

Mental Health Diagnosis (if known, check all that apply)

Is there an Intellectual and Developmental Disability (IDD) diagnosis? * Please select one Yes Suspected Unknown No

Is there a history of Substance Use/ Abuse? * Please select one Yes Suspected Unknown No

Trauma History (if applicable, check all that apply)

Are services requested for: * Please select one Individual (Child) Individual (Adult) Individual and Family

Is this a court ordered service? * Please select one Yes No

Clinical/ Case Management Services

Family-Centered Services (CPS Cases Only, check all that apply)

Referring Agency * Please select one Judges District Attorney Public Defenders Client Attorney Adult Probation Juvenile Probation CPS CASA Crisis Intervention Team Jail Staff Other Law Enforcement Schools Community Other

Other (please specify) *

Phone Number of Referring Party: *

Email of Referring Party: *

Is there a specific BHS Program you have contacted in regards to your client? Please select one No Yes, Recovery and Reintegration Yes, Jail Diversion/ BJA Yes, Juvenile Diversion/ SOURCE Yes, Infant Toddler Program

Date of Referral (Today's Date) *