Wellness Work Care Coordination Referral Form Survey

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* 1. Who is making this referral?

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?

Yes

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

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)?

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

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?

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?

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?

18-24

25-34

35-44

45-54

55-64

65+

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

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?

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)?

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?

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)?

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?

Yes

Don't know

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

Yes

Don't know

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

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)?

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?

Question Title

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

Question Title

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

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

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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

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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?

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

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

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

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

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

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

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

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

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

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

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

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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?

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

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* 25. Is this person active military/veteran?