New Painted Horse Recovery Referral Form

Painted Horse Recovery Referral Form

PHR Provides Substance use recovery support to people who are ages 18 and up and identify as Native American. This form can be completed by either agency or a person seeking recovery support. We have provided a short self assessment that will help interested parties determine if Painted Horse Recovery will be an effective choice.
Painted Horse Recovery Service overview

PHR has drop in support at our recovery center. These services are open to anyone wanting recovery support and they include 12 step meetings, recovery events and skill building groups. We also offer free recovery mentor services to ages 18 and up who live in Multnomah county.
Painted Horse Recovery Service Assessment
Generally, people wanting to engage in our services meet at least one of the following criteria. If none of these apply to you, then PHR services are not likely to meet the need you are trying to address. Please check all that apply.*

Using drugs and/or alcohol is causing issues in my life and I want to stop it from happening.I want to stop using drugs and/or alcohol.I'm being pressured to address my drug and/or alcohol use by someone/something else (friends/family/court/school/employer/ect..)Painted Horse Recovery Is being suggested by a social service provider.I am unsure if my drug and/or alcohol use is a problem for me, but I am interested in learning more about what recovery is.Other
If you answered yes to any of the previous statements, please continue.
What type of Painted Horse Recovery support do you need?*

Recovery Mentoring (someone who helps you find/sustain recovery)Mutual-Aid Recovery Support (12 steps and other types of recovery)
What, if any, other services do you think you need*

DetoxResidential treatmentMental Health TreatmentHousingEmploymentEducationPrimary CareEducationDentalOther
Name*

First NameLast Name
Individuals Gender*
Individuals Phone Number*
If the individuals does not have a phone number, please fill form out with contact info the individual can provide.
Individuals Age*
Individuals Email*
Individuals Address*
Referring Agency Information (if applicable)*
Anything else we should know?*
Should be Empty:

Painted Horse Recovery Referral Form

Painted Horse Recovery Service overview

Painted Horse Recovery Service Assessment

If you answered yes to any of the previous statements, please continue.