RE-LINK Referral - St. Louis Integrated Health Network (IHN)

Participant Identification Information

First Name of Person Referred

First name of person being referred to IHN for services

Last Name of Person Referred

Last name of person being referred to IHN for services

Date of Birth

Primary Language

Participant Contact Information

Street Address

Address line 2

City

State

ZipCode

Phone

Participant phone number

Additional Information for Potential Participant

Does this participant meet the eligibility criteria? (see below)

1. Justice involvement within the last 90 days (date of referral) 2. Preference will be made for those who are aged 18-45 years 3. Currently incarcerated in the local jail with a settlement court date within 30 days of the date of referral 4. Currently incarcerated in a Missouri State Corrections facility 5. Felony or Misdemeanor charges 6. Currently or planning to reside in St Louis City/ County 7. Identified need in social determinants of health (specify)

Referral Status

Incarceration status

How long have they been in custody:

Referral Details

Attorney Name (First and Last)

Attorney Phone

Probation/Parole Officer Name (if applicable):

Probation/Parole Phone

Most Recent Docket/Case Number

Date of next court appearance

Type of appearance

Please provide a brief description of outcomes of the client’s last court appearance

Please list any known mental illness diagnosis:

Social Determinant of Health Need 1

Social Determinant of Health Need 2

Social Determinant of Health Need 3

Social Determinant of Health Need 4

Social Determinant of Health Need 5

What additional information should we know in considering acceptance into the program?

Please add your name, contact info, organization:

person submitting referral

Who is making the referral

Other referral source:

RELINK Referral Form

Participant Identification Information

Participant Contact Information

Additional Information for Potential Participant

Referral Details