Women and Family Intervention Services - Referral Form Date of Referral* MM slash DD slash YYYY Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SSN* Phone*Race*WhiteBlackAmerican Indian or Alaskan NativeAsianNative Hawaii or other Pacific IslanderMulti-RaceAlt. PhoneD.O.B.* MM slash DD slash YYYY Gender*MaleFemaleOtherPregnantYesNoDue Date MM slash DD slash YYYY Prenatal CareYesNoPhysician Name Marital Status* Single Married Divorced Separated Legally Separated Education Level*Below or in Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12High School GEDSome CollegeAABAMA/MSPh.D.Special SchoolVocational SchoolDCF/FFN*YesNoFSFN/FFN Case ID Number* EmploymentFull TimePart TimeMilitaryUnpaid Family WorkerRetiredUnemployedHomemakerStudentDisabledInmateReferred from (agency's/physicians name)* Child(ren)*NameAgeCustody Mental Health/Psychiatric Issues Current Criminal Justice Involvement*YesNoExplain Current Criminal Justice Involvement:Past Criminal Justice Involvement*YesNoExplain Past Criminal Justice Involvement:Previous Treatment(s)*YesNoExplain Previous Treatments:Last Known Use* MM slash DD slash YYYY Substance(s) Used Urinalysis Results* Urinalysis Date* MM slash DD slash YYYY Recent refusals to provide urinalysis*YesNoExplain Recent Refusals:Friends or family concerns about substance use*YesNoExplain Friends & Family Concerns:Client is REQUESTING WFIS services*YesNoMandated/Court Ordered*YesNoPast Involvement with WFIS services*Additional Attachments Included*YesNoExplain Additional Attachments:**Shelter order & Case Plans are required to be sent when applicable** Concerns regarding the home environment/Additional Information/CommentsReferral Contact* First Last Referral contact agency* Referral Contact Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referral Contact Phone*Referral Contact Fax*Referral Contact Email* Supervisor Name* First Last Δ