Beyond Opioids Online Referral Form

Online Referral Form

Welcome to the Beyond Opioids online referral system! Beyond Opioids is a special justice project between Legal Aid of Arkansas and Center for Arkansas Legal Services, providing legal services for low-income Arkansans impacted by the opioid crisis and other substance use disorders (SUD). Please fill out this form if you are a SUD provider and your low-income client needs legal assistance in a civil (NOT criminal matter). Kindly, carefully read the instructions below before filling out this form.

After we receive your referral, our staff will do an eligibility screening to ensure the person needing legal services (the applicant) fits our income guidelines (up to 250% of the federal poverty guideline) and there is no conflict of interest (i.e. our firm has represented or is representing the person adverse to the applicant). If there is a conflict, we cannot accept the case and will notify the applicant. If there is no conflict, we will contact the applicant to do an income eligibility screening. If we are unable to assist your client because of a conflict or if they are over-income, we will notify you that the applicant is not eligible for our services.

If eligible, we will contact the applicant for a full intake and provide the appropriate level of service (legal information, legal advice, limited scope representation, or full representation).

Please note that we give top priority to applicants who are referred by a Beyond Opioids partner through this form. However, applicants may also access our services directly through our Beyond Opioids VIP Helpline at (479) 239-9048. More information about the project can be found at www.beyondopioids.org.

I confirm that I am a SUD provider and I have received permission from my client to submit this referral on their behalf and my electronic signature below attests to this. *

Clear

Information About the Applicant

Please provide the following information on behalf of the applicant to allow us to perform a conflict check and identify which law firm will handle the application.

Applicant's Name *

First Name Last Name

Applicant's Date of Birth

Applicant's Last 4 Digits of SSN

Applicant's County of Residence *

Applicant's Email *

example@example.com

Applicant's Phone Number *

Please enter a valid phone number.

Is it safe to leave a voicemail on the applicant's phone number? *

Yes No

Name of the Adverse Party (Example: If assistance sought is in a Divorce case, the name of the applicant’s spouse)

First Name Last Name

Summarize the Applicant's Situation *

Note: If you do not have the applicant’s DOB or SSN information, please let the applicant know we will be contacting them to get this information in order to do a conflict check. During that first contact, we will also do an income eligibility screening.

OUD/SUD Nexus

This project is primarily for clients who are struggling because someone in the family is in active use, treatment, or recovery from opioid use disorder (OUD) or other substance use disorder (SUD).

We do not share this information to individuals or entities outside of this project. We collect this to determine the level of priority to give a case. Beyond Opioids gives top priority to clients who are impacted by the opioid crisis.

Is the person you are referring in active use, treatment, or recovery from OUD/SUD? *

Yes No

The next question is about opiates. Opiate types are prescription opioids, fentanyl, heroin. See CDC's guide for more information at https://www.cdc.gov/opioids/basics/index.html

Are opiates involved? *

Yes No

What substances are involved? *

Meth Marijuana Alcohol Other

Is there someone else in the family in active use, treatment, or recovery from opioid use disorder? *

Yes No

What is the relationship (i.e. child, parent, sibling, spouse, significant other, grandparent, etc.) between the person you are referring to us and the person with OUD/SUD? *

This project is primarily for people with OUD/SUD, however, the legal aid firms that staff the project help the broader poverty population and we will forward your referral to them for assistance.

Information About the Referrer

Please provide the following information about yourself as the referring partner so we can communicate with you when the case is ineligible for our services or if we need more information to move forward.

Referrer's Name *

First Name Last Name

Referrer's Job Title

Referrer's Organization *

Referrer's Email *

example@example.com

Referrer's Phone Number

Please enter a valid phone number.