WCDC Referral Form

Referral Form

Submit a referral and securely authorize the exchange of information to help our care team coordinate services and begin the intake process.
Referral Partner Information
Referral Agency / Organization Name*
Contact Person Name*
example@example.com
Facility Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Facility Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Method

PhoneEmailFax
Referred Patient Information
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Language
Insurance Type

MedicaidMedicarePrivateNone
Is the client pregnant, or has the client delivered a baby within the last 90 days?

YesNoUnknownType option 4
Is the client currently being cared for in a facility such as a hospital, skilled nursing facility (SNF), or jail?

YesNoUnknown
If yes, please specify name and expected discharge date (if applicable)
Has the client been treated with medication for opioid use disorder in the past?

YesNoUnknown
If yes, where?
Referral Details
Does the client have opioid use disorder, or need help stopping opioids such as fentanyl, heroin, or prescription pain pills?

YesNoUnknown
Reason for Referral / Services Requested

Medication for Opioid Use Disorder (MOUD)SUD CounselingPerinatal SupportComprehensive Support Services (case management, peer support, housing/employment navigation, transportation assistance, and social service coordination)
Additional Notes / Relevant Background (please include at least 2–3 sentences for clients currently hospitalized or transitioning to another facility, such as a SNF)
Urgency Level

RoutineUrgencyCourt-Ordered
Supporting Documents Upload (optional: PDF, DOC, JPG, PNG)

Cancelof
Release of Information Acknowledgment
Referral Partner Signature*
Date*

MonthDayYear
Date
Should be Empty:

Referral Form

Referral Partner Information

Referred Patient Information

Referral Details

Release of Information Acknowledgment