Referral Form
LifeLine RCO & LifeLine Respite ....... a place to breathe
Date
-
Month
-
Day
Year
Referral Source
DCF Indian River
DCF Martin
DCF PSL
DCF Okeechobee
Network Provider
Hospital
Mental Health Court Martin
Mental Health Court PSL
Mental health Court IRC
Mental Health Court Okeechobee
TCHSC
MCSO
IRSO
PSLSO
RiteLife Services Staff
Drug Court PSL
Drug Court IRC
Drug Court Martin
Drug Court Okeechobee
Other
Leave any comments or concerns for the referring person:
Email of referring person:
Contact number of person referring:
Status of Referred Individual
Homeless
Parent of Child Removed or investigated
Forensic
Incarcerated
Substance Use Detox or Treatment
Mental Health Court
Drug Court
Consumer name:
First and Last Name
Consumer Contact Number
Consumer date of birth:
Date
Consumer Social Security number:
Phone
Referral to which Program
Life Line Okeechobee Recovery Community Organization
LifeLine PSL Recovery Community Organization
LifeLine Peer Respite
PATH
SOAR
Why is this individual being referred to RiteLife Services, Inc.?
Peer Support
SOAR (SSI/SSDI, Access, Outreach, Recovery) Benefits
Engagement
Group- Education
Group - Self-Help
Outreach/Engagement
Other Resources
Education Group
Please Select
WRAP
WHAM
Anger Management
Suicide Support Group
Peer Support Group
Relapse Prevention
Mood Management
Recovery Support Education
Basic Recovery Fundamentals
Change your Thinking
Personal Growth
Is there currently a Release of Information for RiteLife Services, Inc.?
Yes
No
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