Wellness Work Care Coordination Referral Form Survey

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1. Who is making this referral? (Required.)

Name

Email Address

Phone Number

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2. Do you have permission to refer this person to the Wellness Care Coordination Program OR are you referring yourself? (Required.)

Yes

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3. What is your association to the person being referred to the program? (Required.)

Self (you are referring yourself to the program)

Probation/Parole/Court Representative

Primary Care Provider (PCP, Specialists)

SUD/Behavioral Heath Provider

Family/Friend

Child Welfare/CFSA Representative

Other (please specify)

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4. Who is being referred to the Wellness Care Coordination Team (skip section if no phone, email)? (Required.)

Name

Address (If homeless, please include shelter info OR mark NA

Ward

ZIP/Postal Code

Email Address (If not available, please mark NA)

Phone Number

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5. What is the person's date of birth?

Date

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6. What is the person's Social Security Number?

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7. Gender (Required.)

Male

Female

TransMale

TransFemale

Nonbinary

Prefer not to answer

Other (please specify)

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8. Do you have regular access the Internet?

I can access the Internet at any time.

I can only access the Internet at specific times.

I can only access the Internet some of the time, I cannot plan.

I cannot access the Internet

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9. How do you access the Internet? (Choose all that apply)

By phone

By tablet

By laptop or PC

I do not access the Internet

Other (please specify)

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10. What is the person's race/ethnicity? (Required.)

White

Black or African American

African/African Heritage (i.e. Caribbean)

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Middle Eastern

Multiracial/ethnic

Other (please specify)

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11. What is the person's primary language? (Required.)

English

Spanish

Haitian/French Creole

Portuguese

Amharic

Korean

Vietnamese

Chinese

French

Arabic

Other (please specify)

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12. What is the person's age range? (Required.)

18-24

25-34

35-44

45-54

55-64

65+

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13. What is the person's sexual orientation? (Required.)

Heterosexual/Straight

Lesbian

Gay

Bisexual

Asexual

Polysexual

Pansexual

Questioning

Queer

2-Spirited

Other (please specify)

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14. Please identify the person's living situation? (Required.)

Rent/Own

Shelter/Facility/Program

Staying with family or friend

Outside/Tent/Other Situation

Other

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15. Which systems is the person currently involved with (List all that apply)? (Required.)

Re-entry (Coming home or about to come home from incarceration, hospitalization OR inpatient)

Court/Parole/Probation

Substance Use/Mental Health

Primary Care/Medical Specialty

CFSA/Child Welfare

Housing/HUD/SNAP/Other Welfare

Other (please specify)

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16. Does the person have a history of using substances? (Required.)

Yes

Don't know

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17. Which substances is the person CURRENTLY using, please check all that apply (If not using, mark NA)? (Required.)

Heroin

PCP

Cocaine/Crack

Fentynal

Meth

Xanax/Percocet/Codeine

Marijuana

Vape/Nicotine/Tobacco

Alcohol

Mushrooms/Hallucinogens

NA- Does not currently use drugs

Other (please specify)

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18. Does the person have a history of overdose? (Required.)

Yes

Don't know

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19. Does the person have a history of intravenous drug use (IV/needles)? (Required.)

Yes

Don't know

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20. Does the person have any of the following health conditions (please mark all that apply)? (Required.)

HIV/AIDS

Diabetes

Heart disease

Cancer

COVID-19 Complications

Hypertension/High Blood Pressure

Obesity/Malnutrition

Rheumatoid Arthritis/Osteoporosis/Other Muscle or Bone Disease

Multiple Sclerosis/Parkinson's/Other Neurological

Kidney Disease

Liver Disease

Asthma/COPD/Other Respiratory

Erectile Dysfunction

Other (please specify)

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21. Does the person have any of the following behavioral/mental health conditions (please mark all that apply)? (Required.)

Depression Disorder

Bipolar Disorder

Borderline Personality Disorder

Multiple Personality Disorder

Schizophrenia/Schizoeffective

Eating Disorder

Anxiety/OCD

PTSD

Autism Spectrum/Intellectual Disability

ADHD

Other (please specify)

Wellness Work Care Coordination Referral Form

Wellness Works!

Question Title

* 1. Who is making this referral? (Required.)

Question Title

* 2. Do you have permission to refer this person to the Wellness Care Coordination Program OR are you referring yourself? (Required.)

Question Title

* 3. What is your association to the person being referred to the program? (Required.)

Question Title

* 4. Who is being referred to the Wellness Care Coordination Team (skip section if no phone, email)? (Required.)

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* 5. What is the person's date of birth?

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* 6. What is the person's Social Security Number?

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* 7. Gender (Required.)

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* 8. Do you have regular access the Internet?

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* 9. How do you access the Internet? (Choose all that apply)

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* 10. What is the person's race/ethnicity? (Required.)

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* 11. What is the person's primary language? (Required.)

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* 12. What is the person's age range? (Required.)

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* 13. What is the person's sexual orientation? (Required.)

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* 14. Please identify the person's living situation? (Required.)

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* 15. Which systems is the person currently involved with (List all that apply)? (Required.)

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* 16. Does the person have a history of using substances? (Required.)

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* 17. Which substances is the person CURRENTLY using, please check all that apply (If not using, mark NA)? (Required.)

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* 18. Does the person have a history of overdose? (Required.)

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* 19. Does the person have a history of intravenous drug use (IV/needles)? (Required.)

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* 20. Does the person have any of the following health conditions (please mark all that apply)? (Required.)

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* 21. Does the person have any of the following behavioral/mental health conditions (please mark all that apply)? (Required.)

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* 22. Does this person have observable or documented cognitive impairment? If so, at what level?

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* 23. Has this person ever had COVID-19? (Required.)

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* 24. Has this person experienced any type of trauma? (Required.)

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* 25. Is this person active military/veteran? (Required.)

1. Who is making this referral? (Required.)

2. Do you have permission to refer this person to the Wellness Care Coordination Program OR are you referring yourself? (Required.)

3. What is your association to the person being referred to the program? (Required.)

4. Who is being referred to the Wellness Care Coordination Team (skip section if no phone, email)? (Required.)

5. What is the person's date of birth?

6. What is the person's Social Security Number?

7. Gender (Required.)

8. Do you have regular access the Internet?

9. How do you access the Internet? (Choose all that apply)

10. What is the person's race/ethnicity? (Required.)

11. What is the person's primary language? (Required.)

12. What is the person's age range? (Required.)

13. What is the person's sexual orientation? (Required.)

14. Please identify the person's living situation? (Required.)

15. Which systems is the person currently involved with (List all that apply)? (Required.)

16. Does the person have a history of using substances? (Required.)

17. Which substances is the person CURRENTLY using, please check all that apply (If not using, mark NA)? (Required.)

18. Does the person have a history of overdose? (Required.)

19. Does the person have a history of intravenous drug use (IV/needles)? (Required.)

20. Does the person have any of the following health conditions (please mark all that apply)? (Required.)

21. Does the person have any of the following behavioral/mental health conditions (please mark all that apply)? (Required.)

22. Does this person have observable or documented cognitive impairment? If so, at what level?

23. Has this person ever had COVID-19? (Required.)

24. Has this person experienced any type of trauma? (Required.)

25. Is this person active military/veteran? (Required.)