Referral Form

To refer a client to UHHR please complete this form and we follow up with you within two-three business days. 

Today's Date:

Provider Clinic:

Name of person making referral:
Patient/Client Name:

Date of Birth:

Preferred Phone:
Is client being helped by:
Client Address:
Country of Origin:
Year of Initial Violence:
  Type of traumatic exposure:
  Personal History of:
Violence perpetrated by:
Current Syptoms:

Other Information: