Referral Form Community is at the Heart of Recovery Fill out the Confidential Referral Form Below. Your Name Your Email Your Phone Patient's Name Patient's Email Patient's Phone Date of Birth City State Drug of choice When did they last use it? If more than one drug when did they last use each drug? Are they on maintenance medication like Suboxone or methadone? YesNo If yes, what program do they go to for their medication? Do they have an ID?YesNo If yes which state is the ID? What insurance do they have? Please provide the Social Security Number to verify insurance. Please Select Office—Please choose an option—MarylandCincinnatiDaytonKentucky Service Requested—Please choose an option—Substance Abuse Intensive Outpatient and Outpatient CounselingPsychosocial Rehabilitative ServicesCommunity Psychiatric Supportive Treatment ServicesMental Health CounselingTransitional HousingPeer SupportMedication ManagementMobile Treatment ServicesPsychiatric Rehabilitation ServicesResidential Detox & Withdrawal Management (ASAM Levels 3.1, 3.3, and 3.5)
