Urban Trauma Center

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Urban Trauma Center

Email *

Option 1

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Referring Agency: *

Date *

Referring Provider *

Self Referral

Name (first/middle/last)

Client Information

Name (first/middle/last) i.e. John P. Doe

If under 18

Guardian's name and phone number

Pronouns *

DOB *

YYYY

Address (City, State, Zip Code)

Phone number (please specify if mobile/home) *

Email *

Race

American Indian or Alaska Native

Asian

Black/Asian

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Unknown

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Ethnicity

Check all that apply

Non Hispanic or Latino

Cuban

Mexican

Puerto Rican

Other Specific Hispanic

Prefer not to answer

Unknown

Required

Gender Identity *

Female

Male

Transgender

Non Binary

Prefer not to answer

Sexual Orientation *

Asexual

Bisexual

Gay

Heterosexual

Lesbian

Pansexual

Polysexual

Queer

Questioning

Choose not to disclose

Other

Primary Language *

Insurance Type

Mark only one circle

Husky/Medicaid

Private

None

Other

Other:

Does client need any accommodations? *

Deaf/serious difficulty hearing

Blind/serious difficulty seeing

Difficulty concentrating, remembering, or making decisions

Serious difficulty walking or climbing stairs

None

Other:

Client Availability (please check client preferences) *

Morning

Afternoon

Evening

Not Available

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Homeless in the last 6 months

Mark only one circle

Yes

Unknown

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Substance Use

Mark only one circle

Yes

Unknown

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If yes, describe choice and usage?

Please check all areas that client had a history of our currently experiencing.

Check all that apply

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Feeling isolated

Thoughts of hurting self or would be better off dead *(REQUIRES Immediate consult with supervisor)

Trouble falling asleep, staying asleep or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about themselves, thoughts or being a failure or letting themselves or family down

Trouble concentrating on things, such as reading the newspaper or watching TV

Feeling nervous, anxious or on edge

Not being able to stop or control worrying or worrying too much about different things

Feeling afraid as is something awful might happen

Neglecting responsibilities due to driniking

Has a relative, friend or a doctor that has been concerned about their drinking

Involved in substance abuse

Has experienced domestic violence

Has witnessed physical and/or sexual abuse, verbal abuse or assault, neglect, bullying or community violence

See/hear things that others don't see

Recent loss/grief

Difficulty coming out to peers/family/friends

Experiencing Nightmares

Having problems with self regulation

Any safety concerns? Provide short explanation

Using inappropriate language

Lack of attention span and /or focusing

Showing aggressive behaviors toward self, peers, and/or others.

Other:

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