REFERRAL FORM

REFERRAL FORM
To: SYNERGY RECOVERY INSTITUTE
Address: 1818 New York Ave, Suite 225, Washington, DC 20002 Phone: 202-873-5155 | Email: intake@sr-institute.com
Full Name
Date of Birth

MonthDayYear
Date
• Medicaid Number:
Gender

Other
• Address:
City/State/ZIP
• Phone:
Format: (000) 000-0000.
Email
example@example.com
• Preferred Contact Method

Other
2. Referring Case Manager / Agency
• Agency Name
• Case Manager Name
• Phone:
Format: (000) 000-0000.
Email
example@example.com
• Date of Referral

MonthDayYear
Date
Please provide a brief explanation of why the client is being referred (check all that apply)

Other (please specify)
I, the undersigned, authorize [Professional Counselor Group] to provide counseling services and share relevant information with my case manager for the purpose of care coordination.
Case Manager Signature: Date
Case Manager Signature: Date

MonthDayYear
Date
For Office Use Only:
• Intake Date:

MonthDayYear
Date
• Assigned Counselor
• Notes
Should be Empty: