Instructions: Module 51 - TheMeasurementGroup.com

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 51: Referral Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

This form must be completed by project staff. It is not intended to be filled out by the client.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not been already entered on the form, look up your code in the table below. Site codes are 3 letters.

Site Code	ORGANIZATION
AHF	AIDS Healthcare Foundation
DCW	Center for Women Policy Studies
CCY	Cook County Hospital
EBO	East Boston Neighborhood Health Center
EMY	Emory University
HAI	Haitian Community AIDS Outreach Project
HFY	Health Initiatives for Youth
IND	Indiana Community AIDS Action Network
IAC	Interamerican College of Physicians and Surgeons
HOP	Johns Hopkins University
LAR	Larkin Youth Center
VER	Medical Center Hospital of Vermont
MIC	Michigan Protection and Advocacy
MDH	Missouri Department of Health
COL	Mountain-Plains AETC
NYS	New York State Dept. of Health
OTR	OUTREACH, Inc.
PRO	PROTOTYPES
SNY	Research Foundation of SUNY
FOR	The Fortune Society
MSP	University of Mississippi Medical Center
REN	University of Nevada School of Medicine
WAS	University of Washington Center for AIDS and STD
TEX	University of Texas Health Science Center
VNA	Visiting Nurse Association of LA
STL	Washington University School of Medicine
WBI	Well-Being Institute

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Referral Date. Enter the numbers representing today's date (the date of the referral) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Use your observations to determine if client is male or female. If the client is biologically male, darken the circle next to "Male." If the client is biologically female, darken the circle next to "Female." Ask him or her if necessary.

Instructions: Darken the circle for any formal referral (s) you made for the client today. Please note that the column on the left side of the form lists agencies to which you may have made referrals. These agencies have been coded by your project. Please consult your project director to ensure consistent recording of referral agencies. The column on the right side of the page lists referral topics. Be sure to darken circles for both the agency and the kind of referral.

Referrals Made for	Working Definition
HIV Testing	A referral was made to a facility or program for testing to detect the presence of HIV antibodies.
STD Clinic	A referral was made to a clinic that specializes in treating sexually transmitted disease.
Emergency Medical	A referral was made for medical services provided in a hospital or emergency care setting. Such services are usually required because of the sudden onset of an illness or because of an injury-related accident.
Medical Outpatient	A referral was made for medical services provided on an appointment basis in an outpatient setting such as a doctor’s office or community clinic. Services may include routine physical examinations or services required in the treatment of a specific illness or condition.
Medical Inpatient	A referral was made for medical services provided in a residential ("sleep-in") setting such as a hospital, convalescent home, or physical rehabilitation center.
Social Services	A referral was made to a service provider for assistance not described elsewhere in these working definitions.
Food/Drop In	A referral was made for food, clothing, drop in counseling or other basic needs. This category includes government supported programs such as the Food Stamp program as well as non-profit private programs such as food share programs run by community-based organizations.
Shelter/Housing	A referral was made for short and/or long-term housing or assistance in locating and obtaining suitable, on-going, or transitional shelter. The referral was made to agencies that may be government supported such as public housing authorities or private non-profit organizations providing immediate shelter such as the Red Cross or church-affiliated organizations.
Educational/Vocational Training	A referral was made for information related to obtaining education, instructional assistance, and/or training to obtain employment. Such services may be provided by government supported programs, local schools and colleges, and/or community-based programs.
12 Step/Self-Help Group	A referral was made to a group focusing on a topic of concern to members of that group. These include 12-Step groups such as Alcoholics Anonymous (AA), or Narcotics Anonymous (NA) as well as support groups that focus on specific health conditions such as herpes or Kaposi’s sarcoma.
Case Management	A referral was made to an agency that provides a range of client-centered services that links clients and other family members with health care, psychosocial services, and other services to ensure timely, coordinated access to appropriate services. Includes on-going assessment of the needs of clients and family members.
Mental Health Services: Outpatient	A referral was made to an outpatient mental health services agency providing services which may include individual and group counseling/therapy, psychiatric evaluations, crisis intervention, psychosocial assessment, and other services.
Mental Health Services: Inpatient	A referral was made to an inpatient mental health services agency providing services which may include individual and group counseling/therapy, psychiatric evaluations, crisis intervention, psychosocial assessment, and other services in a residential ("sleep-in") setting.
Substance Abuse: Detox	A referral was made to an agency that helps individuals detoxify from substance abuse. The agency may use either a medical model or social model detoxification approach. Maintenance programs such as methadone maintenance may also be included in this referral category.
Substance Abuse: Outpatient	A referral was made to an agency that provides outpatient or day treatment substance abuse treatment or counseling. Day treatment programs usually require a substantial commitment of time on the part of the client and are characterized by a very structured therapeutic approach which includes an array of professional interventions. Outpatient treatment, on the other hand, may only require a minimal regular commitment of time on the part of the client such an hour a week an counseling may be conducted by either a professional therapist or a paraprofessional counselor.
Substance Abuse: Inpatient	A referral was made to an agency that provides inpatient substance abuse treatment or counseling. Included in this category are programs that run the spectrum from medical model hospital programs and very structured therapeutic communities to less structured "sober living" or "drug-free" living environments.
Family Planning	A referral was made for services for reproductive health. These services may include information on contraception, birth control and pregnancy.
Legal Assistance	A referral was made to an agency which provides legal services.
Public Assistance	A referral was made for government sponsored public assistance such as AFDC, SSI, or General Relief.
Child Care	A referral was made to an agency which provides care for the client's children.
Family Support	A referral was made to an agency that provides therapy and counseling services to resolve problems or conflicts among family members. Examples of such services include parent training, assertiveness training, or values and role clarification counseling.
HOPWA	A referral was made to the HUD Housing Opportunities for Persons With AIDS program.
Support	A referral was made for counseling or self-help opportunities focused on special problems of the client, including groups that focus on specific health conditions such as herpes or Kaposi’s sarcoma.
Transportation	A referral was made for assistance with transportation such as obtaining bus or subway passes, or rideshare program.
Alternative Therapy	A referral was made for assistance in seeking alternatives to standard medical approaches to treatment for an illness. Such alternatives may include acupuncture treatment or herbal remedies.
Treatment Advocacy	A referral was made for assistance in obtaining medical treatment. These referrals may be made when the client has expressed difficulty or disappointment in obtaining the kinds of medical interventions he or she needs.
Nutrition	A referral was made for services that provide help with ensuring optimal nutrition. These referrals may include nutrition counseling and/or education.
Other	A referral was made for services not coded elsewhere.