Human Service Referral Form

Request for Human Services (internal agencies only)
Referral Agency  
Phone Number
Client Demographics
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Pregnancy Yes     No
Veteran Yes     No
Assistance Type Eligibilty/Health Coverage  Basic Needs
Mental Health Service-Children  Primary Care/Health ServicesOther
Urgent Referrals Safety Concern  Self-Harm  Housing Displacement
A representative from Human Services will contact you regarding your referral. Someone will
respond to your referral within 24 hours. Please allow 48 hours if submitted after 5 p.m. Friday.
Thank you.
Human Services Division
8000 North Stadium Drive
Houston TX 77054