Human Services Internal Referral Form

Human Service Intake Form

Request for Human Services (partnering agencies only)
Referral Agency  
Phone Number
Client Demographics
-------------------------------------------------------------
 
 
 
 
Pregnancy Yes     No
Household Size
Household Income
 
 
 
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
For more information about site based services terms, go to
http://www.houstontx.gov/health/HumanServices/definitions.html
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