Joey's Place: Renewal's Pathway to Independence: Confidential Contact & Referral Form

Joey's Place Confidential Contact & Referral Form

Use this form to contact our program or submit a referral. Your information will be handled confidentially and used only to respond to your inquiry or referral.
Are you completing this form for yourself or for someone else?
- Your full name
  
  First NameLast Name
- Your email address
  example@example.com
- Your phone number
  Please enter a valid phone number.Format: (000) 000-0000.
- Preferred contact method
- Name of person being referred
  
  First NameLast Name
- Full Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Gender Identity
- Ethnicity
  
  Other
- Current Living Arrangement
- Emergency Contact Name
  
  First and Last NameRelationship to referred individual
- Emergency Contact Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Is it safe for us to leave a detailed message if we cannot reach you directly?
- Are you a current resident of Allegheny County(You must be a resident of Allegheny County to qualify. Your address must be listed on your Photo ID)
- Current or Most Recent Address (street, city, state, ZIP)
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Social Security Number
- Date of Birth
  
  MonthDayYear
  Date
- How urgent is this referral?
- Upload: Copy of Identification (e.g., driver’s license, state ID, passport)
  
  Cancelof
- Please provide a brief description of the situation and what support is being requested.Do not include highly sensitive personal identifiers or financial information.
- Insurance Provider Name
- Policy / Member ID Number
- Group Number (if applicable)
- Policy Holder Name
- Policy Holder Date of Birth
  
  MonthDayYear
  Date
- Current Employment Status
  
  Other
- Employer Name
- Job Title / Position
- Work Schedule (days/hours or shift description)
- Was a Level of Care Assessment (LOCA) completed within the last 6 months?
- Referral Source and Level of Care Assessment
  
  AgencyContact Person (if known)
- Description of Substance Use Disorder and Mental Health Diagnosis:
- List substances used in the last 90 days.
- Frequency of use
- Duration of use (how long they have been using)
- Date of last use
  
  MonthDayYear
  Date
- Prior treatment history
- If yes, please provide type of treatment, dates, and locations
- Please list all current prescription medications (prescription name, dosage, frequency of dose and prescriber)
- List all over the counter medications and supplements you are taking.
- If referring from a treatment provider, you are required to provide one of the following documents via email (email address) or upload.
- Cancelof
- Confidentiality Notice
- By submitting this form, you understand and agree that: - The information you provide will be used only to review your inquiry or referral and to contact you, if requested. - We will take reasonable steps to protect your information and keep it confidential in accordance with applicable privacy laws and our internal policies. - This form is not intended for emergencies. If you or someone else is in immediate danger, please contact local emergency services. Please review our full privacy notice on our website for more details about how we handle your information.
- Security check
- Should be Empty:

Joey's Place Confidential Contact & Referral Form