Tamil Italian Hindi Javanese Thai Cantonese Korean Burmese Haitian Creole Turkish Kannada Unknown Telugu Gujarati Other: Marathi Polish ___________________________________________ Religion: Protestant Buddhist Pentecostal None Catholic Mormon Other Jewish Orthodox Christian Unknown Muslim Hindu *Marital Status: Never Married Divorced/Annulled Other Married Widowed Unknown Separated Civil Union *Primary Referral Source: Self Employee Assistance Program Probation/Parole Family/Friend Clergy/Church/Synagogue Police Mental Health Provider Dept. of Children and Families Shelter Substance Abuse Provider Dept. of Social Services Dept. of Corrections Medical Health Practitioner Dept. of Developmental Disabilities Other School Community Referral Unknown Employer/Supervisor Order *Pregnancy Status: No Yes Client Doesn't Know Client Refused Data Not Collected Tobacco: Yes No Unknown
Tamil Javanese Korean Turkish Telugu Marathi Italian Thai Burmese Kannada Gujarati Polish Hindi Cantonese Haitian Creole Unknown Other: ___________________________________________ Religion: Protestant Catholic Jewish Muslim Buddhist Mormon Orthodox Christian Hindu Pentecostal None Other Unknown *Marital Status: Never Married Married Separated Divorced/Annulled Widowed Civil Union Other Unknown *Primary Referral Source: Self Family/Friend Mental Health Provider Substance Abuse Provider Medical Health Practitioner School Employer/Supervisor Employee Assistance Program Clergy/Church/Synagogue Dept. of Children and Families Dept. of Social Services Dept. of Developmental Disabilities Community Referral Order Probation/Parole Police Shelter Dept. of Corrections Other Unknown *Pregnancy Status: No Yes Client Doesn't Know Client Refused Data Not Collected Tobacco: Yes No Unknown
CT_HMIS_Statewide_PATH_Family_Intake_Form_with_DDaP_-_7.2_1.docx