Referral
We are commiteed to ensuring affordable access to care for everyone.
Self Questionnaire
Do you hide drugs or alcohol?
Have you ever been arrested for DUI and continue to drive drunk?
Have drugs or alcohol cause you legal problems?
Have you ever overdosed?
Is your usage affecting your job, school. or causing problems within your family?
Do you use in the morning when you wake up to steady your nerves?
Have you ever felt guilty about your drug or alcohol use?
Have you ever promised yourself or others that you would cut down your usage only to find that you are unsuccessful in doing so?
If you answered "yes" to any of these questions, you may need help.
Services Requested
*
Substance Use
Mental Health
Detox Clinic (Men only)
SCHOOL/YOUTH
SCHOOL/YOUTH REFFERAL ONLY: Select a Campus
Please Select
Hilo High School
Honokaʻa High & Intermediate
Pahoa High & Intermediate
Kohala High School
Kohala Middle School
Keaʻau High School
Kaʻu High & Pahala Elementary
OTHER SCHOOL NOT LISTED
Information about the person referred
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Nonbinary
Another Identity
Prefer Not to Answer
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Information
The person referred has insurance?
*
Yes
No
Not applicable (applies to YOUTH/SCHOOL referrals only)
If yes, name of insurance:
FEMALE REFERALS ONLY: PPWDC includes women who are pregnant or have dependent children aged 4 years old and under.
Number of Children 4 and under
Information about the person making the referral
Select One:
Self
ʻOhana
Friend
Other
If other, what is your relationship to the person referred, e.g. Probation Officer, Employer, School Counselor, etc.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Additional Comments:
PLEASE PROVIDE AN EMAIL ADDRESS FOR REFERRAL CONFIRMATION RECEIPT
*
example@example.com
Submit Form
Should be Empty: