ASPIRE SUPPORTIVE & COUNSELING SERVICES, LLC. CONSUMER REFERRAL & SCREENING FORM 130 E. Morgan St. Raleigh, NC 27601 Phone: 919 835-1888 Fax: 919 835-1889

Date of Referral: __________________ Time of Referral: _ ____________________

Name of Referral Source: ______________________________________________

Name of Referring Agency: ____________________________________________

Phone Number of Referral: ________________________ Fax Number of Referral: _______________________

Referral’s Email Address: _________________________________________

The reason the individual is for seeking Services: _________________________________________________________________________

Service(s) Being Requested: SA Therapy Ind. Group MH Therapy Ind. Group

Consumer Information

1. Individual’s Name and age ____________________________________________________________________

2. Individual’s Address ____________________________________________________________________________

3. Residence  Private (Alone With Others)  Family Care Home (__ 6 beds, __7+ beds)  Homeless  Nursing Home Residential (Not Nursing)

4. Phone Numbers: (H) ______________________________ (W) __________________________________(M) _______________________________________

5. Guardian’s Name __________________________________________ Relationship to Individual ________________________________

6. Race: _____________ 7. Gender: M F                8. Marital Status:  Single  Married  Divorced

9. Height: __________ Hair Color: _________ Eye Color: ____________

10. SSN# _______________________________________________

11. Do you have a Physical Disability? Yes  No Do you have a Mental Disability? Yes  No

12. Do you need assistive technologies? (i.e. blind, deaf, disabled) Yes  No

13. Do you need accessible equipment? Yes  No

14. Do you need communication assistance: Yes  No What Type: _________________

15. Do you have difficulty reading or writing English? Yes  No (if yes, please explain)

16. Insurance Type: Medicaid Policy# ___________________________________ Medicare Policy # ______________________________________ Health Choice Policy# ___________________________________ Other: __________________________________________________