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Human Service Referral Form


Request for Human Services (internal agencies only)
Referral Agency
Contact Name
Phone Number
Email Address
	Client Demographics
	-------------------------------------------------------------
Client Name
Phone Number
Email Address
Client Address
Zip Code
Date of Birth
Pregnancy	Yes No
Due Date
Veteran	Yes No
Children
Adults
Other Adults
Preferred Language
Assistance Type	Eligibilty/Health Coverage Basic Needs Mental Health Service-Children Primary Care/Health ServicesOther
If other, please explain
Safety Concerns
Specific information that may be important to assist the client
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