Universal Referral Form

UNIVERSAL REFERRAL FORM

Please fill out this form to refer someone to receive services from SCAN.
Date of referral:

MonthDayYear
Date
Referred by:*

First NameMiddle NameLast Name
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Title:
Name of Referral Agency:
Person Being Referred
Person Being Referred:*

First NameMiddle NameLast Name
Date of Birth:

MonthDayYear
Date
Contact Information for Person Being Referred:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Mobile Phone:
Please enter a valid phone number.
Presenting Problem: Below please describe in as much detail the reason you are making the referral including the problems or needs the person has.
Services you believe the individual being referred may need (check all that apply):*

Substance Use Disorder TreatmentMental Health Treatment *Recovery Support Services *Home Visiting and other support services for families with children 0-5 *Family conflict for families with children 6-17Sexual Assault Services *Parenting Education *Trauma-focused counseling services for youth 3 - 17*Medical Assisted Therapy for adults *Substance Abuse Prevention Education – youth 6-17Not sureOther
* These services are only available in Webb County
Substance Use Disorder Treatment

AdultAdolescent
Mental Health Treatment

AdultAdolescent
Recovery Support Services

AdultAdolescent
Name of Guardian/Caregiver (if any):

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Additional information:
Should be Empty: