NOAH - Client In-Take Referral Form NOAH (Client In-Take Referral Form) Name of Client * Date of Birth * Sex (Check one) Male Female Address * Apt/Suite# * City/Zip Code * Home Phone # * Alternate Phone # * May We Leave Messages At These Numbers? * Yes No Alternate Only Home Only If Under 18, Parent/Guardian(s) Signature(s) Medicaid # (And/Or) Insurance Medical Number Was an evaluation assessment completed? Yes or No? Check Referal Source * Adult Parole Authority CCDCFS Cuyahoga County Juvenile Court School System Parent ADD Treatment Provider Self-Referral Other, Please Specify Does Client Have Substance Abuse Problem? Yes No What is the Substance? Is Transportation Required? Yes or No? Is Childcare Required? * Yes No If Yes, How Old Are The Children? Is Residential Treatment Required? Yes or No? Name of Person Submitting Referral: * Organiztion Phone # Submitting this completed form will begin the process.