Substance Abuse & Addiction Services Referral Form

1
Please list your full name* This field is required.
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email* This field is required.
example@example.com
4
Primary Phone Number* This field is required.
Area Code
Phone Number
5
Date of Birth* This field is required.
Date of Birth
Month
Day
Year
6
Sex* This field is required.
Female
Male
7
Name of Insurance Company:* This field is required.
8
Please Provide Your Insurance Policy Number* This field is required.
9
Reason for Calling:* This field is required.Why did you contact us?
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Large
Normal
Small
Ok
Ok
10
List any other information that you would like us to be aware of?Any pre-existing physical condition or mental illness?
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Ok
Ok
11
Have you ever been a client at HCO Behavioral Health Services?* This field is required.
YESNO
12
Are you currently clean? * This field is required.Must provide a clean urine screen upon admission
YESNO
13
Substance Abuse History* This field is required.
Drug of Choice
Amount Used
Frequency
Last Used
Method
Substance #1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Substance #2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Substance #3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Substance #1
Substance #2
Substance #3
Drug of Choice
Row 0, Column 0
Amount Used
Row 0, Column 1
Frequency
Row 0, Column 2
Last Used
Row 0, Column 3
Method
Row 0, Column 4
Drug of Choice
Row 1, Column 0
Amount Used
Row 1, Column 1
Frequency
Row 1, Column 2
Last Used
Row 1, Column 3
Method
Row 1, Column 4
Drug of Choice
Row 2, Column 0
Amount Used
Row 2, Column 1
Frequency
Row 2, Column 2
Last Used
Row 2, Column 3
Method
Row 2, Column 4
1 of 3
14
Treatment History: Have you been to treatment before?* This field is required.If so, list treatment location, treatment dates, and type of treatment (inpatient/outpatient).
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Small
Ok
Ok
15
Do you have access to transportation?* This field is required.
YESNO
16
What is your preferred group meeting time?* This field is required.
Evenings 6pm-9pm
Daytime 1pm-4pm
Daytime 9am-12pm
17
How did you hear about us ?* This field is required.
Instagram
Facebook
Email
Google
Doctors Office
Hospital
Other
18
Where would you like your appointment to be scheduled?* This field is required.
Baton RougeLafayette
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