Addiction Treatment Resources
Name of Program
Parent agency, if any
Director/Contact/Name
First Name
Last Name
Agency/Program Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone Number
-
Area Code
Phone Number
Alternate/After Hours Phone Number
-
Area Code
Phone Number
Are there specific hours when referrals are accepted? If so, please list:
Website:
Are patients accepted at your facility 24/7, or are there limited intake hours? Please specify:
Bed Capacity
Back
Next
Average Length of Stay
Which types of payment do you accept?
Private insurance
Medicaid
Medicare
VA
Self-pay
Accept SOR funding/provide charity beds
If self-pay, what is approximate cost of stay?
Is your facility for:
Males
Females
All genders
Do you allow couples to enter together?
Yes
No
Are patients/clients allowed to smoke?
Yes
No
Other
How often are smoke breaks?
Do you accept sex offenders?
Yes
No
Other
Do you accept patients/clients on house arrest?
Yes
No
Other
Do you accept pregnant women?
Yes
No
Are you able to accommodate non English speakers. Please specify:
Yes
No
Is there a cutoff as to how far along the pregnancy can be (ie will only take up to 3rd trimester, etc...)
What is procedure for getting clearance for accepting pregnant patients (letter from OB, ER med clearance, etc....)
Are there any mental health conditions that preclude admission? (schizophrenia, suicidal ideation, history of suicide attempts, etc) Please specifiy:
Are there any medical conditions that preclude admission (Advanced Cirrhosis, Insulin-pump dependent Diabetes, Dialysis, use of wheelchair etc.) Please specify:
Are patients/clients allowed to have their children stay with them?
Yes
No
What is your policy on family visitation?
Are patients/clients allowed to keep their cell phones on premises?
Yes
No
What is the best description of your facility?
Detoxification
Short term inpatient treatment (less than 30 days)
Long term residential treatment (more than 30 days)
Sober living or recovery housing
Which drugs do you provide detoxification from?
Stimulants (ie...Methamphetamines, Cocaine)
Opioids/Heroin
Benzodiazepine
Alcohol
Other
Do you accept patients who are prescribed and wish to take a controlled substance, such as opioids/benzos?
Is medical clearance required for admission?
Yes
No
Do you accept clients who are on the following types of medication who plan to stay on them?
Vivitrol
Suboxone
Methadone
What services do you offer onsite?
Psychiatric care
Medication-assisted treatment
Intensive Outpatient (IOP)
Therapy
Peer recovery coaching
Other
Optional - Provide a description or tell us anything else we should know about making a referral to your facility:
If you require an application, please attach here:
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