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
Date
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

CallTextEmailOther
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
Date
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

YesNo
Date of scheduled appointment

MonthDayYear
Date
I have completed a level of care assessment and am referring a client for treatment at JADE Wellness Center?

YesNo
Date of Evaluation

MonthDayYear
Date
Level of Care Recommended
Other Recommendation
Please list any and all times you are available to attend group sessions

MorningAfternoonEvening
Preferred Referral Site:

MonroevilleSouthsideWexfordOther
Additional Services Recommended

Medication Assisted Treatment (MAT)Psychiatric Med ManagementCertified Recovery SpecialistN/AOther
Type of Medication Assisted Treatment (MAT)

Sublocade/BrixadiVivitrolBuprenorphine (Suboxone)Other
Desired Treatment Start Date

MonthDayYear
Date
Desired MAT Start Date

MonthDayYear
Date
Toxicology Screen Results
Please include the following in your referral:

ASAMLevel of Care AssessmentScreening QuestionairreRelease of Information or TPO Consent
You can attach all of the documents to this form below or email them to:
Alex@myjadewellness.com

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