Referral for Services

Form
Referral for Services

If unable to complete online, please print and fax completed form to 502-579-8254. Questions? Contact us at 502-579-8253.
Name of Person Completing Form*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Patient Name*

First NameLast Name
Referral Date *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Patient DOB*

MonthDayYear
Date
Insurance*
Any Previous Treatment Episodes
Transferring from Another Facility*
Does the patient have a preference of an appointment date for Intake? We will do our best to accommodate. ***This appointment will take approximately 3-4 hours. Patient will need to be present at 5am.

MondayTuesdayWednesdayThursdayFriday
Is the patient currently abusing opioids? *
If no, we would need to discuss admission, please email customersupport@renewedbc.com for more information.
If answered yes, above please list reported substances abusing:
Has the patient been physiologically dependent on opioids for at least 1 year prior to now?*
If answered no, we would need to discuss admission, please email customersupport@renewedbc.com for more information.
Is the patient 18 years of age or older and meeting all other legal criteria for admission?*
If answered no, we will not be able to accept per state regulations.
Is the patient abusing other substances, including alcohol and benzodiazepines, to a degree which may place them at risk for intoxication and/or withdrawal?*
If answered yes, above please list reported substances abusing:
Does the patient have any urgent or critical medical or mental health needs that will need to be addressed prior to admission into the program?*
If answered yes, please indicate urgent or critical needs:
Should be Empty:

Form

Referral for Services