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Use this form to send direct referrals for Outpatient Substance Abuse Treatment, Intensive Outpatient Treatment, and Psychiatric Rehab Services for Adults.
Referral Type (select all that applies)
ASAM 3.3 Residential Treatment
ASAM 3.1 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)
ICD 10 Diagnosis Code: (Required for PRP referrals)
Reason for Referral (include frequency and severity of the problem)
Referring Provider/Agency Staff Signature (Include Credentials and Date): By typing in your name and date below, you agree that your are the party listed as the referral source and are electronically endorsing the information provided in this referral for the purpose of Outpatient, Intensive Outpatient, or PRP services.
Thanks for the referral. We will be reaching out soon!
Submit Your Referral
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