DHS/DMH/LAHSA REFERRAL FORM FOR INTERIM HOUSING The information provided below will be used to determine program eligibility and the most appropriate housing resource. REFERRING ENTITY INFORMATIONDate of Referral MM slash DD slash YYYY Name of Referring Entity First Middle Last Referring Staff Name First Middle Last Referring Staff Title Referring Staff Phone NumberReferring Staff Email Address Alternate Contact Name First Middle Last Alternate Contact Title Alternate Contact Phone NumberAlternate Contact Email Address Referring Entity Type Private Hospital Private Non-DHS Urgent Care Jail/Custody Setting (Non-ODR Skilled Nursing Facility CBEST Program Mental Health Outpatient Treatment Facility Substance Use Disorder Residential Treatment Facility Substance Use Disorder Outpatient Treatment Facility (including Withdrawal Management Program) CARE Court Street-Based Outreach Program DHS ICMS Provider and participant is not being served by one of the above entities. Victim Service Provider Other Specify Victim Service Provider Outreach Team LAHSA Outreach Team DMH Outreach Team DHS Outreach Team Outreach Team Name SPA 1 - MHA LA SPA 1 - LAFH SPA 2 - LAFH SPA 2 - SFVCMHC, Inc. SPA 3 - USHS SPA 4 - C3 Skid Row Team (Red) SPA 4 - C3 Skid Row Team (Purple) SPA 4 - C3 Skid Row Team (Yellow) SPA 4 - C3 Skid Row Team (Blue) SPA 4 - The People Concern SPA 4 - The Center at Blessed Sacrament SPA 4 - Homeless Health Care LA SPA 4 - Exodus Recovery NELA SPA 4 - Exodus/LAC + USC Team SPA 5 - C3 Venice Team SPA 5 - C3 Santa Monica Team SPA 5 - St. Joseph Center SPA 6 - HOPICS SPA 6 - SSG MLK Campus SPA 6 - SSG CD8 SPA 7 - PATH SPA 8 - MHA LA SPA 8 - Harbor UCLA Campus Team PATH Metro Team Other PARTICIPANT INFORMATIONParticipant Name First Middle Last Date of Birth MM slash DD slash YYYY AgeSocial Security No.(Required) Known Not Known Enter Social Securtiy No.(Required)Medical Record No.Participant Maiden Name(Required) Place of Birth(Required) HMIS# (if known)CHAMP ID # (if known)IBHIS # (if known)CES Acuity ScoreCES Score is for an Youth/Adult Family Matched to Housing Resource? Yes No Participant DemographicsRace and Ethnicity(Select all that apply) American Indian, Alaskan Native, Indigenous Hispanic/Latina/e/o White Client doesn’t know Middle Eastern or North African Client prefers not to answer Black, African American, or African Asian or Asian American Native Hawaiian or Pacific Islander Data not collected Gender Identity Man (Boy if child) Woman (Girl if child) Transgender Non-Binary Questioning Culturally Specific Identify (e.g., Two-Sprits) Client doesn’t know Client prefers not to answe Data not collected Other Indicate the participant’s gender bed preference Male Female No Preference Pronouns She/Her He/Him They/Them Other Sexual Orientation Asexual Pansexual Queer Straight/heterosexual Gay or Lesbian Bisexual Questioning Other Have you served in the US Armed Forces? Yes No Client doesn't know Clients prefers not to answer Data not collected Primary Language Spoken Limited English proficiency requiring translation services? Yes No PhoneEmail Participant Current Location SPA 1 - Antelope Valley SPA 2 - San Fernando Valley SPA 3 - San Gabriel Valley SPA 4 - Metro LA (Non Skid Row) SPA 4 – Skid Row Only SPA 5 - West LA SPA 6 - South LA SPA 7 - South East LA SPA 8 - South Bay/Long Beach Other (For Others option) Specify address including city and zip code or cross streets where participant typically resides (Information required for placement options)Is the participant chronically homeless (Experienced homelessness for 365 consecutive days or longer, or experienced at least four episodes of homelessness in the last three years that total a year or longer)? Yes No If no, length of Homelessness (Months) <2 2-3 4-6 7-9 10-11 How was chronic/length of homelessness verified? HMIS 3rd Party Certification Participant Self-Reported Is the participant currently connected to an Office of Diversion and Re-entry (ODR) funded program? Yes No If yes, specify the name of the program and provider Is the participant currently in law enforcement custody, due to the lack of housing, while awaiting an upcoming trial or court hearing? Yes No If yes, specify the anticipated discharge date MM slash DD slash YYYY Did the participant exit an institution within the last 90 days? Yes No If yes, specify the discharge date: MM slash DD slash YYYY Select type of Institution Jail/Prison Third Choice Hospital Emergency Room Substance Use Treatment Facility Foster Care Detention Center Residential Care Facility Is the participant conserved or does the participant have a conservatorship hearing pending? Yes No If yes, type of conservatorship LPS Probate Other Considerations AB109 Probation Convicted of Arson Registered Sex Offender Veteran N/A Fleeing/attempting to flee Domestic Violence Human Trafficking or Sex Trafficking Sexual Assault N/A HOUSEHOLD INFORMATION(Only complete if the participant is requesting to be housed with family)Minor ChildrenName First Last Date of Birth MM slash DD slash YYYY AgeGender Male Female Other Legal Custody Yes No Name First Last Date of Birth MM slash DD slash YYYY AgeGender Male Female Other Legal Custody Yes No Name First Last Date of Birth MM slash DD slash YYYY AgeGender Male Female Other Legal Custody Yes No Name First Last Date of Birth MM slash DD slash YYYY AgeGender Male Female Other Legal Custody Yes No Name First Last Date of Birth MM slash DD slash YYYY AgeGender Male Female Other Legal Custody Yes No (If there are more minor children to be housed with participants, provide the above-requested information in the “Additional Information” section below.) Additional Adults in HouseholdName First Last Date of Birth MM slash DD slash YYYY AgeGender Male Female Other Qualified Dependent Yes No Name First Last Date of Birth MM slash DD slash YYYY AgeGender Male Female Other Qualified Dependent Yes No *Qualified dependents are over age 18, incapable of employment due to mental/physical disability, and dependent upon the participant for financial support. (If there are more adult individuals to be housed with participants, provide the above-requested information in the “Additional Information” section below.)Is the participant pregnant? Yes No If yes, how many weeks?Are any other members of the household pregnant? Yes No If yes, what relationship to the participant? Additional InformationPRESENTING ISSUE(S) Select all that apply to the participant. Medical Mental Health Recent Substance or Substance Use Cognitive Impairments: The participant does not have any of the above issues TUBERCULOSIS (TB) SCREENINGHas the participant had a cough recently that has lasted longer than 3 weeks? Yes No Don't Know Has the participant recently lost weight without explanation during the past month? Yes No Don't Know Has the participant had frequent night sweats during the past month, soaking their sheets or clothing? Yes No Don't Know Has the participant coughed up blood in the past month? Yes No Don't Know Has the participant been feeling much more tired than usual over the past month? Yes No Don't Know Has the participant had fevers almost daily for more than one week? Yes No Don't Know Does the participant has a prolonged cough (> 3 weeks) AND answers yes to any other TB screening question, the participant must be promptly referred to a healthcare provider for an evaluation.(Required) Yes No TB Test Performed Yes No Date Completed MM slash DD slash YYYY Result Chest X-Ray Performed Yes No Date Completed MM slash DD slash YYYY Result ADDITIONAL PARTICIPANT/HOUSEHOLD INFORMATIONSelect all that apply to the participant. Needs assistance with Activities of Daily Living (i.e., bathing, dressing, transferring, toileting, eating) Incontinent of bladder or bowel and independent with the use of incontinence supplies Respiratory issues requiring an oxygen tank Independently uses walker/cane/crutches Independently uses a manual wheelchair Independently uses a motorized wheelchair Cannot transfer (e.g., from wheelchair to bed) Has caregiver support Needs caregiver support Cannot climb stairs Needs bottom bunk Significant visual impairment Significant auditory impairment Other additional information, specify Does any of the above apply to other household members being placed with the head of the household? Yes No If yes, specify Does the participant/household have any animal(s) that will accompany them into Interim Housing? Yes No Is the animal a service animal? Yes No If yes, # of animals:Types Weight Is the animal an emotional support animal? Yes No If yes, # of animals:Types Weight Is the animal a pet? Yes No If yes, # of animals:Types Weight CURRENT SLEEPING/LIVING ARRANGEMENTSelect the category that best describes the participant’s current sleeping/living arrangement. Sleeping in a place not meant for human habitation Shelter/Interim Housing Hotel/Motel fully or partially subsidized by a public or non-profit agency Exiting an institution (Jail/Prison, Foster Care, Detention Center, Residential Care Facility, or Substance Use Treatment Facility) Staying temporarily with family/friends Recent eviction/relinquishing unit to prevent eviction Other specify Street Park Campground Vehicle Other Shelter Name Shelter Funder LAHSA DMH DHS VA Unknown Other Participant has resided for: 90 days or less For more than 90 days AND participant resided in Shelter/Interim Housing, or a place not meant for human habitation before entering the institution Date of eviction/unit relinquished: MM slash DD slash YYYY INTERIM HOUSING PLACEMENT LOCATIONIs the participant willing to reside in a congregate living environment? Yes No Is the participant willing to reside in the Skid Row area? Yes No Is the participant willing to sleep on a top bunk of a bunk bed? Yes No Is there any SPA(s) where the participant would prefer to live in Interim Housing? Select all that apply. SPA 1 - Antelope Valley SPA 2 - San Fernando Valley SPA 3 - San Gabriel Valley SPA 4 - Metro LA SPA 5 - West LA SPA 6 - South LA SPA 7 - South East LA SPA 8 - South Bay Is there any city/cities where the participant would prefer to live in Interim Housing? Yes No If yes, specify: Does the participant have an Interim Housing provider(s) preference? Yes No If yes, specify: Is the participant willing to go to an alternate provider? Yes No Is there any SPA(s) where the participant CAN NOT live in Interim Housing? Select all that apply. SPA 1 - Antelope Valley SPA 2 - San Fernando Valley SPA 3 - San Gabriel Valley SPA 4 - Metro LA SPA 5 - West LA SPA 6 - South LA SPA 7 - South East LA SPA 8 - South Bay Is there any city/cities where the participant CAN NOT live in Interim Housing? Yes No If yes, specify: Additional Required Document AcknowledgementFor referrals submitted to DMH or DHS, check that the below-required documents are included with the referral submission. This is not applicable to referrals submitted to LAHSA. DMH Los Angeles County Department of Mental Health Authorization for Use or Disclosure of Protected Health Information Supplemental Form (Attachment A) for Interim Housing for participants that meet any of the Participant Review criteria on page 1 DHS Notice Of Privacy Practices Acknowledgment Form Supplemental Form (Attachment A) for Interim Housing DHS Authorization for the Use and Disclosure of Health and Social Service Information (New Universal Consent Form) CAPTCHA Δ