Certified Assessment Center

Certified Assessment Center - Direct Admit

If you completed a level of care assessment and are looking to send JADE Wellness Center a direct referral, please begin by completing this form.
Date of referral:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Name

First NameLast Name
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Contact
Emergency Contact Name:

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Client SSN:
Client DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance:
Other:
Insurance ID Number:
Referral:
Referral Organization:
Referral Contact Name:

First NameLast Name
Referral Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referral Email
example@example.com
Does the individual have an appointment scheduled with JADE Wellness Center
Date of scheduled appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have completed a level of care assessment and am referring a client for treatment at JADE Wellness Center?
Date of Evaluation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Level of Care Recommended
Other Recommendation
Please list any and all times you are available to attend group sessions
Preferred Referral Site:
Additional Services Recommended

Other
Type of Medication Assisted Treatment (MAT)

Other
Desired Treatment Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday
Desired MAT Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please note that we are unable to assign clients to treatment schedules more than 30 days in advance. You should not expect outreach until closer to your requested admission date. Clients are assigned to groups and clinician caseloads based on their treatment start date, as open spots may be filled by individuals beginning treatment sooner.
Toxicology Screen Results
Please include the following in your referral:
Ensure all the above listed items are included as attachments - if you are missing an ASAM, LOCA or Release we cannot process this referral

With any questions please call: 412-380-0100
Reason for Referral / Additional Information
Communication

Once the direct admission has been processed, a team member from JADE Wellness Center will contact you by phone or email to confirm your treatment start date and schedule.
Referral Documents

In order to initiate a direct referral please attach a consent to release information/TPO Consent, Level of Care Assessment, and an admission ASAM form.
Upload Files

Include ROI, Level of Care Assessment and Screening documentation
Cancelof
Should be Empty:

Certified Assessment Center - Direct Admit

Referral:

Communication

Referral Documents