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: Insurance Type: Medicaid Medicare Private None 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: Employment TCA SSI SSDI Retirement Other None Primary Substance Method of Use: Oral Smoking Inhalation Injection Other Length of Current Use: 1 month or less 1-6 months 6 months-1 yr 1yr or more Unknown Secondary Substance Method of Use: Oral Smoking Inhalation Injection Other Length of Current Use: 1 month or less 1-6 months 6 months-1 yr 1yr or more Unknown Tertiary Substance Method of Use: Oral Smoking Inhalation Injection Other Length of Current Use: 1 month or less 1-6 months 6 months-1 yr 1yr or more Unknown Problem Areas: Educational Primary Support Occupational Health Care Housing Homeless Legal Social Environment Unknown Send Message Download Our Referral Form Let's Connect On Social Media Facebook-f Twitter Instagram Linkedin-in Skype
