Referring agency/person Agency or Provider: Name of person making referral: Referral Phone: Referral Source Email: Individual being referred Client First Name Client Last Name Phone Street City State/Province Zip Country Gender:--None--Female Male Other Missing or Unknown Date of Birth: Date of Arrival U.S.: Date of Arrival to Utah: Primary Care Dr/Clinic: Details of Referral Country of Origin:--None--Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (NOT DRC) Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Democratic People'S Republic Of Korea Democratic Republic Of The Congo (Zaire) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands (Malvinas) Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Special Administrative Region of China Hungary Iceland India Indonesia International Waters Iran (Islamic Republic Of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Lao People'S Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Special Administrative Region Of China Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Monaco Mongolia Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Ireland Northern Mariana Islands Norway Occupied Palestinian Territory Oman Other Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic Of Korea Republic Of Moldova Réunion Romania Russian Federation Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Province Of China Tajikistan Thailand The Former Yugoslav Republic Of Macedonia Tibet Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Republic Of Tanzania United States United States Virgin Islands Unknown Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Country of Origin Other: Languages:Amarigna Amharic Arabic Arabic (Sudanese) Armenian Arsi Assyria Bantu Bosnian Burmese Croatian Dagomba Dari Dioula English Ewe & Mina Farsi French Fula Guaragigna Hadiyigna Italian Kabye Keldani Kikongo Kiluba Kingwana Kinyarwanda Kisawanda Kiswahili Kurdish Lingala Mai Mai Mandinka Mashi Meru Missing/Unknown Nilotic Nubian Oromigna Oromo Other Pashto Rohingya Romanian Russian Serbian Sidamigna Somali Somaligna Spanish Swahili Ta Bedawie Tigrigna Tigrinya Tshiluba Turkish Turkoman Ukrainian Wolof Languages Other: Reason for Referral: What services referred to?:Mental Health Case Management Medical Support Other (Please Specify in Notes) Client is aware of Referral?: Notes: Waitlist Triage Questions Any current or upcoming housing crisis?:--None--Yes No RHS-15 score: Any suicidality or psychiatric urgency?:--None--Yes No Any urgent asylum or immigr. concerns?:--None--Yes No Any current family issues (DCFS/DV/etc)?:--None--Yes No Legal concerns besides asylum?:--None--Yes No Triage Notes: