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



    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?

    If yes, what program do they go to for their medication?

    Do they have an ID?

    If yes which state is the ID?

    What insurance do they have?

    Please provide the Social Security Number to verify insurance.

    Please Select Office

    Service Requested