Client Information

    Your Name (required)

    Date of Birth (required)

    Your Address (required)

    Your Email (required)

    Contact Number (required)

    Please select from the following services

    Substance Use EvaluationSubstance Use TreatmentMental Health EvaluationMental Health TreatmentPsychiatric EvaluationAnger ManagementFamily Therapy

    Financial Status / Funding Sources
    Court MandatedMedicaid CoverageNo Medicaid CoverageCoordinated Family CareSelf-PaySelf-Referred

    Please provide a brief explanation for referral
    Client is mandated for substance abuse evaluation.Client tested positive for illicit substance use while on probation.Client is a Non-English speaking. Require Spanish services.

    Comments

    Agency Information

    Agency

    Contact Phone

    Name

    Email

    Client Referral Form

    Referring Agency Name

    Contact Person

    Your Address (required)

    Phone # (required)

    Extension

    Fax #

    Client information

    Name:

    Phone#

    D.O.B.

    Reason for Referral

    To provide the best services for your client, please have your agency attach the following information:

    1. Comprehensive Intake & Recent toxicology results (if applicable)

    2. Most recent Treatment Plan

    3. Recommendation for Discharge/Treatment & all applicable DAP Notes/SOAP Notes

    4. Medical Records (If applicable)/Signed Record Release (s)

    **One of our staff members will contact you to confirm receipt and identify if client is appropriate for treatment (intake) at our agency**

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