Certified Recovery Support Services Referral Form

Certified Recovery Support Services Referral Form
Client Information
Date of Referral*

MonthDayYear
Date
Clients Name*

First NameLast Name
Clients Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clients Email*
example@example.com
Clients Phone Number*
Please enter a valid phone number.
Is it okay to text/email?*

YesNo
Emergency Contact Information
Emergency Contact Person and Relation*
Emergency Contact Persons Phone Number*
Please enter a valid phone number.
Referral Information
Referring Persons Name*

First NameLast Name
Referring Persons Title*
Referring Persons Email*
example@example.com
Referral Phone Number*
Please enter a valid phone number.
Agency/Facility*
Referrals made to the CRS would be by a Doctor’s order, a licensed practitioner of the healing arts (Psychologist, Physician, Psychiatrist, PA, CRNP, LPC or LCSW ), a licensed D & A facility, a Certified Alcohol and Drug Counselor, hospitals, correctional facilities, and other Human Service Agencies
Client Diagnostic Information
Diagnosis*
Does the client have a Case Manager*

YesNo
Name of Case Manager
Agency of Case Manager
Case Managers Phone Number
Please enter a valid phone number.
Recovery Support Domains
What areas is the peer in need of assistance? (Check all that apply)*

Education/VocationEmploymentPhysical HealthDrug and AlcoholEmotional/Mental HealthSocialLiving Arrangements/HousingLegal StatusLegal StatusBasic Needs (Food, clothing, utilities)Recovery SupportsParentingTransportationSafetySpirituality/OptimismFamily (Primary Partnership)Access to ServicesHealth Insurance
Should be Empty:

Certified Recovery Support Services Referral Form

Client Information

Emergency Contact Information

Referral Information

Client Diagnostic Information

Recovery Support Domains