Referral Form

Residential Treatment Referral Form

Step 1 of 3

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SECTION 1: PROGRAM INFORMATION:

Which program/level of care is the current referral intended for?

3.3 Men’s Residential Treatment

3.3 Women’s Residential Treatment

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SECTION 2: CLIENT INFORMATION

First & Last Name

Date of Birth

Month

Day

Year

Social Security Number

Gender at Birth

Male

Female

Current Identified Gender

Home Address

Street Address Address Line 2 City / County State / Province / Region ZIP / Postal Code

Insurance Company Name

Insurance Policy Number

Race/Ethnicity

Marital Status

Married

Divorced / Separated

Single

Emergency Contact First & Last Name

Emergency Contact Phone #

Emergency Contact Relationship

Can we state that we are calling from Mind Your Health and Wellness when calling the phone number listed above?

Yes

Do you have a need for language/interpretation services?

Yes

If Yes, explain.

SECTION 3: REFERRING ENTITY INFORMATION:

Is this a self-referral?

Yes

Entity Name

Referral Source Contact – First & Last Name

Referral Source Contact - Phone #

Referral Source Email Address

Referral Source Address

Street Address Address Line 2 City / County State / Province / Region ZIP / Postal Code

Is this mandated treatment (court, probation, doctor)?

Yes

Release Signed

Yes

DOC ID#:

Is the client currently receiving additional services from other agencies?

Yes - please specify

(i.e., description of services, contact name & phone number, duration of service, etc.)

Previous Treatment History

Please include dates, drug of choice, treatment facility/level of care (detox, mental health, inpatient, etc.)

Individual’s drug(s) of choice

Please include:  Name of Drug  Date of Last Use  Frequency of Use  Any other relevant information

Substance Abuse Diagnosis (DSM5)

Yes - please specify

SA Diagnosis (DSM5)

Mental Health Diagnosis (DSM5)

Yes - please specify

MH Diagnosis (DSM5)

Any history of IV drug use?

Yes - please specify

IV drug use explanation

Any chance of being pregnant?

Yes

Does this individual have a primary care physician? If yes, please provide contact information.

Yes

Primary care physician contact Information

Does the individual have any chronic or acute medical conditions?

Yes

Narrative

Please provide any additional information that may be helpful to the clinician and treatment team assessing this individual.

Mind Your Health & Wellness is an organization dedicated to bring about total recovery through high quality, cost-effective, person-centered Level 3.3 substance abuse residential treatment programs.

Contact Us

Name

Email Address

Message

We Want to Help !

Our approach is centered around the understanding that addiction is an isolating and debilitating disease, that if left untreated can be terminal.

Call (443) 745-0445

Phone

(443) 745-0445

Email

myhwellness@gmail.com