True
False
Field not visible to providers, indicates record was imported from SOR 1 contact form
Please select one of the following options:
* must provide value
I am submitting a client contact form for a new SOR GPRA client.
I am submitting UPDATED contact information for an existing SOR GPRA client. (And a client contact form was already completed for them under the SOR II grant.)
I am submitting a client contact form for a new SOR GPRA client.
I am submitting UPDATED contact information for an existing SOR GPRA client. (And a client contact form was already completed for them under the SOR II grant.)
Please verify that you have reviewed the client consent form with your client and they have consented to participate in the GPRA data collection.
My client has signed the consent form and agrees to participate.
My client has signed the consent form and agrees to participate.
Client ID
* must provide value
Can only be up to 15 alphanumeric characters. Please refer to SORColorado.org for more information about the client ID convention.
Client First Name
* must provide value
Client Last Name
* must provide value
Date of GPRA Intake
* must provide value
Today M-D-Y
Please select which of the following fields you would like to update:
* must provide value
Primary Phone Number
Secondary Phone Number
Address
Email
Primary Phone Number
Secondary Phone Number
Address
Email
Primary Phone Number
* must provide value
Street Address
* must provide value
State
* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
* must provide value
Client ID
* must provide value
Can only be up to 15 alphanumeric characters. Please refer to SORColorado.org for more information about the client ID convention.
Client First Name
* must provide value
Client Last Name
* must provide value
Date of GPRA Intake
* must provide value
Today M-D-Y
What is your client's preferred language?
English Spanish Other
If other, please list client's preferred language:
Family/Friend Medical/Mental Health Professional Peer Navigator Court Mandate Case Manager/Social Worker Other
If other, please list who referred the client to treatment:
How long did it take your client to travel to today's appointment?
Less than 30 minutes About an hour About an hour and a half Two or more hours
How did your client travel to today's appointment?
Shared Ride/Carpool Drove his/herself Walked Ride from family/friend Public transportation Hired vehicle (i.e. taxi, Uber, Lyft, etc.) Other
If other, please list client's mode of transportation to today's appointment:
Does the client have an email address that we may contact them at?
* must provide value
Yes
No
Does the client have an existing phone number that we may contact them at? If no, we will contact you for updated contact information when the client is due for follow-up.
* must provide value
Yes
No
Primary Phone Number
* must provide value
Is your client currently experiencing homelessness?
* must provide value
Yes
No
Street Address
* must provide value
State
* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
* must provide value
Is the mailing address the same as the address listed above?
* must provide value
Yes
No
Provide, if available, for clients experiencing homelessness.
Provide, if available, for clients experiencing homelessness.
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Provide, if available, for clients experiencing homelessness.
Provide, if available, for clients experiencing homelessness.
Relationship with Client
* must provide value
Father Friend Mother Sibling Spouse Other
If you selected "other," please list the relationship with the client.
Mobile Phone Number
* must provide value
Father Friend Mother Sibling Spouse Other
If you selected "other," please list the relationship with the client.
Father Friend Mother Sibling Spouse Other
If you selected "other," please list the relationship with the client.
Site ID
* must provide value
103000 103005 103009 103022 105300 109405 109417 109425 150368 159701 159702 159703 159705 159706 159707 164800 164801 164802 176401 177600 177601 177603 177604 177605 178600 179200 179201 181700 182200 211001 250323 250324 250325 250326 250327 250328 250329 250330 250331 250332 250333 250334 250335 250336 250337 250338 250339 250340 250341 250342 250343 250344 250345 250346 250347 250348 250349 250350 250351 250352 250353 310010 310011 310012 310013 310014 310015 310016 310017 310018 310019 310020 410010 410011 410012 410013 410014 410015 410016 410017 410018 410019 410020 410021 999999 MU0001 MU0002 MU0003 MU0004 MU0005 MU0006
For instructions on how to determine your site ID, visit the Client ID Convention guide at https://www.sorcolorado.org/sor-gpra/resources.
Clinician/Staff First Name
* must provide value
Clinician/Staff Last Name
* must provide value
Clinician/Staff Email Address
* must provide value
Clinician/Staff Phone Number
* must provide value
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