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.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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.
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