Referral for Substance Use Disorder and Related Services

Referring Agency Information

Name of Agency

Agency Name, if not listed

Date

Primary Contact Name

Phone Number

Extension

Secondary Contact Name

Secondary Email

Secondary Phone

Extension

Agency Fax Number

Release of Information

Is there a Release of Information (ROI) form attached to this referral?

Yes

Agency Being Referred To

Name of Agency

Agency Name, if not listed

Service Site

Site Street Line 1

Site Street Line 2

Site City

Site State

Site ZIP Code

Primary Contact Name

Phone Number

Fax Number

Purpose of Referral

Examples: SUD treatment, behavioral health services, housing, counseling, medication management, employment assistance, etc. Include as many details as helpful

Will the client remain in services with the referring agency?

Yes

Feedback is requested

Yes

Comments

Client Information

Legal First Name

Legal Last Name

Preferred Name

Date of Birth

Address

Please enter address below where client can pick up/get mail

Street Line 1

Street Line 2

City

State

ZIP Code

Phone Number

Parent or Legal Guardian (If under 18)

Personal Pronoun Preference

Gender

Is Client Pregnant?

Yes

Client has access to video/phone conferencing

Yes

Veteran

Self pay

No Insurance, needs financial counseling

Potentially Eligible for Recovery Works

Other

If Other, provide details

Medical Information

Are there any medical or behavioral health concerns that need to be known for this referral?

Yes

If Yes, provide details

Examples may include: wheelchair-bound, has visual/hearing impairment, recent suicidality, needs oxygen, etc.

Medication

Is the client taking or needing to take any medications that need to be considered for this referral?

Yes

If Yes, provide details

Examples may include: benzodiazepines, medication assisted treatment, etc.

Time Form Completed

Referral for Substance Use Disorder and Related Services

Referring Agency Information

Release of Information

Agency Being Referred To

Purpose of Referral

Client Information

Address

Alternate Contact (someone who always knows where client is)

Payment Information

Medical Information

Medication

Referral for Substance Use Disorder and Related Services

Referring Agency Information

Release of Information

Agency Being Referred To

Purpose of Referral

Client Information

Address

Alternate Contact (someone who always knows where client is)

Payment Information

Medical Information

Medication

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