Add New Application

Human Services Internal Referral Form

Human Service Intake Form


Request for Human Services (partnering agencies only)
Referral Agency
Contact Name
Phone Number
Email Address
Fax#
	Client Demographics
	-------------------------------------------------------------
Client Name
Phone Number
Emergency Contact Name
Emergency Contact Number
Relationship
Email Address
Client Address
Zip Code
Date of Birth
Pregnancy	Yes No
Due Date
Household Size
Children
Adults
Household Income
Monthly
Yearly
Marital Status
Gender
Ethnicity
Race
Preferred Language
Assistance Type	Assessment of Human Services Needs Client Access-Health Coverage Service Linkage Basic Needs/Services Mental Health Service-Children Chronic Disease Primary Care PhysicianFood-SNAP Other
If other, please explain
	For more information about site based services terms, go to http://www.houstontx.gov/health/HumanServices/definitions.html
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. MSC Operations and Human Services 8000 North Stadium Drive Houston TX 77054