TRT Referral for Services

Referral for Services

Outpatient Substance Use Treatment
Referred Individual's Information:
Todays Date:*

MonthDayYear
Date
Full Name of the individual being referred to Cenikor:*
First Middle Last
Address*

Address

Street Address Line 2

CityState

Zip
Home Phone #:
Cell Phone #:*
Which Location is Closest to the above individual?

Amarillo, TXDecatur, TXDeer Park, TXIrving, TXKilleen, TXSan Antonio, TXStephenville, TX
Referred individuals need to be aware that they will receive an email soon after this document is submitted with further instructions.
Referred Individual's Email Address:*
This email will be used to contact individual with Instructions
Social Security:
Gender:*

MaleFemale
Date of Birth:*

MonthDayYear
Date
Race:*
Contractually Required Information

The following questions are based on state funding requirements.
Is the individual a Veteran?*

YesNo
Is the individual Pregnant?

YesNoN/A
Is the individual an Injecting Drug User?

YesNo
Does the individual have Medicaid?

YesNo
If individual has Medicaid, please provide the number.
Does the individual have Private Insurance?

YesNo
If individual has private insurance, please provide the Name/ID #:
Does the individual have an open CPS Case?*

YesNo
Is the individual on Probation/Parole?*

YesNo
Individual is being Referred by:

We will provide updates to this person on the referral process as well as .
Agency:*
Name:*
Contact Number:*
Email: (this will be used for updates on progress)*
example@example.com
Use this space to provide as much detail on the reason this individual is being referred to STAR Council for a substance use screening. *
Thee more information you can provide the better. This information can be useful with individuals who are insistent that they do not have a drug problem.
In accordance with CFR42 Part 2 Subpart B §2.13.c: Cenikor requires a consent to release information for all referred individuals.
Attached supportive documents here:

Browse Files
client consent, family plan, court papers, etc. Cancelof
Cenikor offers Substance Use Outpatient in the following locations in Region 3:

Irving, TX

Decatur, TX

Stephenville, TX

Also in other regions as well:

Amarillo, TX

Deer Park, TX

Killeen, TX

San Antonio, TX

Referrals received are reviewed in the order rreceived to process for scheduling. We will contact referred individual, via email address provided above, with instructions on submitting the state required documents.

Individuals are contacted within one to two business days of receiving the Referral. For questions regarding referrals previously submitted please email svillenotifications@cenikor.org .
Should be Empty:

Referral for Services

Referred Individual's Information:

Contractually Required Information

Individual is being Referred by: