INSTRUCTIONS
Please fill out the attached referral and ensure all areas are fully completed. The packet must be TYPED. Once completed and signed, please submit this HIST referral form and any supporting materials to your supervisor/agency representative for review, if required. Ensure a Release of Information Form is included with your materials. ***Referral Form must be submitted electronically to HIST@saccounty.gov by the 1st and 3rd Monday of every month by 3:00PM*** Any referral forms received after the above deadline will not be considered for the following scheduled HIST meeting. HIST meets on the 1st and 3rd Thursday from 1 to 3 PM. Once scheduled, an electronic email invitation will be sent to the referring party with additional details regarding the meeting, location, and time.
REFERRAL INFORMATION

Referring Party Contact Information:
Name of Referring Party:	Type here.	Agency:	Type here.
Title:	Type here.	Phone:	Type here.	Email	Type here.
Sup Name:	Type here.	Phone:	Type here.	Email:	Type here.

Client General Information:
Name:	Type here.	DOB/Age :	Type here.	Gender:	Type here.
Primary Race:	Type here.	Ethnicity:	Type here.	Primary Language:	Type here.
Phone:	Type here.	# of children 0-5:	Type here.	# of children 6+:	Type here.
HMIS #	Type here.	Avatar Case #	Type here.

Does this individual have a fixed nighttime residence indoors?	☐ Yes, ☐ No – If NO, skip to Location Description
Address:	Type here.	City:	Type here.	State:	Type here.	Zip:	Type here.
Location Description:	Type here.

Income Source & Monthly Amount: Choose from options in drop down
Choose One	$ Amt.	Choose One	$ Amt.	Choose One	$ Amt.

Employment History:	☐Yes, ☐ No If yes, list any employment history and/or employable skills the client may have:

Is Client Connected To Positive Resources? Mark all that apply
☐ Food Banks	☐ Medical Services	☐ Access to shower	☐ Access to a phone	☐ Child Care
☐ CalFresh	☐ Clothing	☐ Caregiver / IHSS	☐ Payee Services	☐ Family Support
☐ Transportation	☐ AOD/ AA	☐ Legal Assistance	☐	☐
☐ Housing Voucher:	Indicate which voucher: Type here.

Goals And/Or Purpose Of Case Conference: Note to Lead: Copy & Paste to Action Plan goal section	Type here.
Describe history of housing instability or homelessness: Include dates of program enrollments and/or services received, program/service information, reasons for housing instability or return(s) to homelessness, if previously housed:	Type here.

Overall assessment of client’s strengths, needs, barriers and status in current service plan Note to Lead: Copy & Paste to Action Plan in similar section
Strengths	Barriers	Needs
Type here.	Type here.	Type here.

☐ Mark to indicate that a Release of Information Form was signed by client and is included with your referral.

Referring Party Signature:	Type here.	Date:	Type here.
Supervisor Signature:	Type here.	Date:	Type here.