Referrals

Referrals are made when it has been determined there is a need for higher levels of care not offered.

SUBSTANCE USE DISORDER REFERRAL

REFERRAL SOURCE INFORMATION

CONSUMER INFORMATION

Currently Employed:

Y N

Military Experience:

Y N

Still Active:

Y N

Active Insurance:

Y N

Insurance Type:

Registered Sex Offender

Y N

Currently on Parole/Probation:

Y N

Cigarette Use

Y N

Prescribed Medication

Y N

History

Number of Arrest in Last 30 Days:

Number of Arrest in Last 12 months:

Medical Challenges:

Physical Disabilities:

# of Treatment Episodes:

Primary Source of Income:

Primary Substance

Method of Use:

Length of Current Use:

Secondary Substance

Method of Use:

Length of Current Use:

Tertiary Substance

Method of Use:

Length of Current Use:

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Referrals

SUBSTANCE USE DISORDER REFERRAL

REFERRAL SOURCE INFORMATION

CONSUMER INFORMATION

History

Primary Substance

Secondary Substance

Tertiary Substance

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