Resettlement and Medical Screening Referral

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Referring agency/person

Agency or Provider:
Name of person making referral:
Referral Phone:
Referral Source Email:

Individual being referred




Client Address:
Gender:
Date of Birth:
Date of Arrival U.S.:
Date of Arrival to Utah:
Primary Care Dr/Clinic:

Details of Referral

Country of Origin:
Country of Origin Other:
Languages:
Languages Other:
Reason for Referral:
What services referred to?:
Client is aware of Referral?:
Notes:

Waitlist Triage Questions

Any current or upcoming housing crisis?:
Any suicidality or psychiatric urgency?:
Any urgent asylum or immigr. concerns?:
Any current family issues (DCFS/DV/etc)?:
Legal concerns besides asylum?:
RHS-15 score:
Triage Notes: