PATH Referral Form - Touchstone Mental Health

This field is for validation purposes and should be left unchanged.

Date of Referral*

Chosen Name

First Last

Legal Name*

First Last

What pronouns do you use?

He/Him/His
She/Her/Hers
They/them/theirs
Other

What is your gender identity?

Legal Gender Marker*

Female
Male
Non-binary

Date of Birth*

Race/s*

Native American
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Communication Preference:*

Phone Call
Text
Email
Video Call
Other

If you selected other, please provide more information

Language Preference/s

Do you need or want an interpreter?

Yes
No

Social Security Number (No Dashes)*

Eligibility Criteria, check all that apply.

Be a single adult, 18 years or older, who has been diagnosed with a serious mental illness, OR
Be a family with an adult who has been diagnosed with a serious mental illness (a mental illness "that seriously limits a person's capacity to function in primary aspects of daily living such as personal relations, living arrangements, work, and recreation."), AND
Must be at imminent risk of homelessness, homeless, or transitioning from an institution.

Mental Health Diagnoses

Are you currently homeless? Please list the date you became homeless and list any other times you have been unhoused in the last 4 years.

Are you being discharged from an institution (i.e. hospital, IRTS facility, jail, etc.) and will be homeless at discharge? Please list the name and location of the institution, your admission date, and your discharge date.

Are you at risk of homelessness, such as being evicted? Please describe the situation.

What programs would you be interested in? Check all that apply.

SSI/SSDI Outreach, Access, and Recovery (SOAR) is a program that assists states and communities end homelessness for adults with a serious mental illness by providing increased access to Social Security disability benefits.
Case Management services provides assistance with navigating resources, referrals to community based programs and services, and assists with transitioning to long-term case management and/or a Care Coordination agency.
Direct assistance with basic needs, for example, a one time payment of rent assistance, access to bridging, etc. This program does not provide clothing, hotel stays, out of state travel, or other personal needs.
Housing assistance by providing navigation and screening for eligible housing and making referrals to housing services.

Who would you like to have listed as your emergency contact? Please complete a release of information for this person using the form provided on the PATH program page.

First Last

Relationship

Phone

Who is the person submitting this referral (if not a self-referral)?

First Last

Agency Name

Agency Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Role

Phone

Email

Number

Submit the following forms using the upload document tabs below, check all that apply.

Proof of a mental health diagnosis. Examples of documents accepted are a PSN, a health summary with your diagnosis listed, medical opinion form, jail or probation form, a diagnostic assessment, a functional assessment, care or treatment plan, etc. If you do not have proof of a mental health diagnosis, please let the intake staff know and they can assist you in getting an assessment. A diagnosis of a mental health disorder is required for PATH.
Complete the Homeless Management Information System (HMIS) release of information. It is provided on the program page and is required to access the PATH program.
An external release of information (ROI) for any person or organization that you give permission for us to talk to about your needs. This is not required, and staff will help determine if a ROI is needed.

Upload document

Max. file size: 128 MB.

Upload document

Max. file size: 128 MB.

Upload Document

Max. file size: 128 MB.