Step 1 of 4 – Client Information 25% Name: Street Address: City, State & Zip Code: Telephone:Email: Best Time to Contact: Morning Afternoon Evening Best Form of Contact: Phone Txt Email Name of Referring Agency: Name of Referral Contact: Telephone:Email: Relationship to client being referred: Family Mental Health Professional Medical Professional Corrections Consent Please contact me immediately for more information.Consent Contact me with an appointment time for the person referred.Consent Contact me if this person does not keep appointment. Reason for Referral Psychiatric Rehabilitation Substance Use Treatment Mental Health Therapy Recovery Housing (for CIHS clients only) Comments: How did you hear about CIHS Services?: Colleague Social Media Internet Another Agency Hospital Brochure/Flier Other Please Specify:* CAPTCHA