Referral for Substance Use Disorder and Related Services
Referring Agency Information
Release of Information
Agency Being Referred To
Purpose of Referral
Examples: SUD treatment, behavioral health services, housing, counseling, medication management, employment assistance, etc. Include as many details as helpful
Please enter address below where client can pick up/get mail
Examples: American Sign Language (ASL), Spanish, Burmese, etc.
Alternate Contact (someone who always knows where client is)
Examples may include: wheelchair-bound, has visual/hearing impairment, recent suicidality, needs oxygen, etc.
Examples may include: benzodiazepines, medication assisted treatment, etc.