Name

First Name

Last Name

Phone

(###)

###

####

Preferred method of contact (for check-ins) *

Check up to two preferred methods

Phone

Online (Zoom, Meet, etc.)

In-Person

Name *

First Name

Last Name

Date of Birth

{dd/mm/yyyy)

MM

DD

YYYY

Ethic or Racial Identity

Of the African Diaspora

Of the Asianic Diaspora

South American or Latin X

European

Other

Insurance? *

Yes

No

CTS member status *

Are you a current member of CTS?

Yes - Standard

Yes - Base

No

No, but I'd like to join

Peer Navigation Support Eligibility *

Please fill out to the best of your ability

Is self-identifying as Black or Brown male

Has had significant difficulty independently and consistently accessing behavioral health services (e.g., relies on emergency department services, has had 2+ inpatient admissions over the last year);

Has been justice impacted or is currently being released from incarceration or being discharged from a hospital or facility-based program;

Has had noticeable to severe functional impairment that interferes with activities of daily living (e.g., hygiene, nutrition, finances, home maintenance, child care, housing, transportation, and/or legal issues);

Has experienced significant (to you) challenges meeting educational or employment goals;

Lives in unsafe or temporary housing;

Does not have sufficient family or other social support, or the supports that are in place are insufficient to help ameliorate or manage the stated condition.

Has a family member that meets one of the above criterion

Address (City, State only) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name *

First Name

Last Name