Substance Use Treatment Referral Form

• Referral Source Information

• Name: *
• Agency: *
• Phone: *
• Email: *

• Client Information

• Client Name: *
• Date of Birth: *
• Address: *
• City: *
• State: * —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Zip Code: *
• Phone Number: *
• Email: *
• School: *
• Grade: *
• Insurance: * YesNo
• Type: *
• MA#: *
• Insurance: * YesNo
• Children: * YesNo
• How many? *

• Parent or Legal Guardian Information

• Name: *
• Relationship to Client: *
• Address: *
• City: *
• State: * —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Zip Code: *
• Phone Number: *
• Email: *
• Do you have legal custody of client: * YesNo

• Please answer the following:

• Is the consumer of Hispanic, Latino, or Spanish origin? YesNoUnavailable
• Race: * WhiteAsianBlack/African AmericanNative HawaiianOther Pacific IslanderAmerican Indian/Alaska NativeNot Available
• How well does the consumer speak English? * WellNot so wellNot at all
• Does the consumer speak another language other than English at home? * YesNo
• If yes, what is the language:
• Number of arrests in the past 30 days: * NoneYes
• If yes, how many?
• Reason for Referral: * In your own words, describe the need for substance abuse treatment.)
• Services Needed: * HousingEducationLegalSupportOther
  If Other, please indicate:

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