Referrals for Services Not Funded By MAI Funds

Referred By

In this reporting period, how many referrals did you make?

Current Reporting Period

Year to Date Total

Of the total reported above, please report the number of referrals you made to each service

Current Reporting Period Year to Date Total

HIV Testing

HIV Testing Counseling

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HIV Treatment

VH Testing

VH Counseling

VH Vaccination

VH Treatment

Mental Health Services (excluding HIV testing counseling and VH testing counseling)

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Substance Abuse Treatment

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Health Care Services (excluding SA, HIV, and VH treatment)

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Supportive Housing

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Other Social Services (Specify) - {{model.viewModel.model.otherSocialServicesDescription}}

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Other Service Type (Specify) - {{model.viewModel.model.otherServiceTypeDescription}}

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In this reporting period, what is the number of particpants who received the service for which they were referred?

Current Reporting Period

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Year to Date Total

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Referrals for Services Not Funded By MAI Funds

Referred By*

Current Reporting Period

Year to Date

In this reporting period, how many referrals did you make?*

Current Reporting Period

Year to Date

Of the Total reported above, please report the number of referrals you made to each service

HIV Testing*

HIV Testing Counseling*

HIV Treatment*

VH Testing*

VH Counseling*

VH Vaccination*

VH Treatment*

Mental Health Services (exclusing HIV Testing counseling and VH testing counseling)*

Substance Abuse Treatment*

{{model.editItemModel.edit.substanceAbuseTreatmentYearToDateCount}}

Health Care Services (excluding HIV testing counseling and VH testing counseling)*

Supportive Housing*

Other Social Services (Specify)*

Other Service Type (Specify)*

Current Reporting Period

Year to Date

In this reporting period, what is the number of participants who received the service for which they were referred?*

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Referrals for Services Not Funded by MAI Funds

Referrals for Services Not Funded By MAI Funds

Referrals for Services Not Funded By MAI Funds