Self Referral Form

  • 1. Are you referring to yourself or a loved one?*
  • Is your loved one willing to engage is treatment
  • What insurance carrier do you have?
  • What is your preferred method of contact? (select all that apply)
  • Format: (000) 000-0000.
  • What is the primary concern that is causing you to reach out?*

  • Substance Use

  • What is the substance(s) of choice? (Select all that apply)
  • How often is the substance use?
  • Has substance use caused any of the following experiences? (Select all that apply)
  • How long has it been since the last episode of use
  • What level of treatment do you think is right for you or your loved one’s substance use treatment?
  • Are there other concerns you would like Tellurian to address with you?*

  • Mental Health

  • What mental health concern is currently the most concerning?
  • What other mental health concerns are present? (Select all that apply)
  • Have you or your loved one experienced any of the following due to mental health struggles? (Select all that apply)
  • What level of treatment do you think is right for you or your loved one’s mental health care?
  • Are there other concerns you would like Tellurian to address with you?*

  • Housing Instability

  • What is you or your loved one’s current housing situation
  • Do you currently have any income?
  • What type of housing services are you looking for?
  • Are there other concerns you would like Tellurian to address with you?*

  • Other Concerns

  • Should be Empty: