Dual Diagnosis and Recovery Support (DDRS)
Referral Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Source
Name of Person/Agency Referring for DDRS
Email
example@example.com
Contact Number for Referral Source
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Referral
-
Month
-
Day
Year
Date
Relationship to Client
Presenting Issues
Primary Mental Health Diagnosis (If Known)
Substance Use Issues (type of substances, frequency, duration)
Symptoms and Behaviors Observed
Current Mental Health Status (e.g. mood, thought patterns, suicidality)
Medical History
Relevant Past Psychiatric Diagnoses and Treatment
Substance Use History
Current Medications (include dosage and frequency)
Any hospitalizations or treatment episodes? (Psychiatric or Substance Use)
Submit
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