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Right Step LLC
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FOR RE-ENTRY TEAM USE ONLY
- Use this form to send direct referrals for Mental Health Therapy, Substance Abuse Treatment, Inpatient Substance Abuse Treatment, and Psychiatric Rehab Services for Adults.
Referral Type (select all that applies)
*
Required
ASAM 3.3 Residential Treatment
Intensive Outpatient Treatment (9 or more hours of service weekly)
Outpatient Substance Abuse Treatment (less than 9 hours of service weekly)
Adult Psychiatric Rehabilitation Services - PRP (6 therapeutic encounters monthly)
Mental Health Therapy
If selecting PRP, indicate the track you would like to start with:
Reentry - Community engagement and access to resources
Vocation - Economic management and stability
Personal Development - Coping with mental illness in the community
Housing - Linkage to resources and housing stability
Client Name
Client DOB
Client Email
Client Phone
Referral Source - Provider/Agency Name: (if self referring, write "self")
Referral Source - Contact Number (if self referring, write N/A)
Referral Source - Email Address (if self referring, write N/A)
Navigator County
Choose an option
Reason for Referral (include frequency and severity of the problem)
Thanks for the referral. We will be reaching out soon!
Submit Your Referral
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