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
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