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):

Ethnicity * Please select one Hispanic/Latino Non-Hispanic/ Non-Latino Prefer not to disclose

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 (Youth Cases Only, check all that apply)

Referring Agency * Please select one Judges District Attorney Public Defenders Client Attorney Adult Probation Juvenile Probation Youth 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 Yes, Juvenile Diversion Yes, Infant Toddler Program Yes, FOCUS Youth Program Yes, Always Parenting

Date of Referral (Today's Date) *