Residential Interest Form v3

Instructions: Please complete this form and upload relevant records. Not having records can delay our review of a person's eligibility.

If you think you meet denial criteria, Please complete the form as we determine eligibility on an individual basis and will likely ask for more information

Important Program Information

Residential patients live in a dormitory-style setting located at our Cherry Blossom location in SE Portland. The length of treatment depends on a person’s use history, recovery goals, progress and readiness. Completion is based on assessment of skill development, treatment engagement, and successful progress through the three phases of treatment.

Individuals in residence are assigned a Certified Alcohol and Drug Counselor and/or a Dual-Diagnosis Counselor. Patients participate in groups that provide education and skill-building; helping to understand their disorders, triggers, and how to build better habits and relationships.

We should note that Fora Health is a tobacco and nicotine product-free facility. This includes outdoor areas. We offer smoking cessation services and Nicotine Replacement Therapy.

Name (As it appears on insurance)

First name Last Name

Preferred Name

Preferred First NamePreferred Last Name

Date of Birth

Race

What is your gender identity (select all that apply):

Please share your pronouns you would like us to use when referring to you. (check all that apply):

SSN (Optional)

Note: Not providing this information may delay the admissions process.

Preferred contact method

Phone Number

Format: (000) 000-0000.

Email

example@example.com

We may contact you via email or text, If you do NOT want to be contacted via text or email, please check the boxes below

County Of Residence

Insurance Plan

Insurance ID Number

Will you (the patient) need interpretive services?

What language

ASL, Español, etc...

Are you a part of an agency or organization that is submitting this referral for a patient?

Name of referring organization

Relation to individual

e.g. Case Manager, Primary Provider, etc.

Name of person making referral

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Will you continue working with this patient if admitted to residential and/or after their discharge?

Is the patient currently incarcerated, hospitalized, in withdrawal management, rapid access center?

What is their projected release/discharge date:

Date

If “other” please explain

Do you (the patient) need assistance performing activities of daily living (ADLs) including showering, toileting and dressing?

Independence with activities of daily living is required for residential patients. Staff is unable to provide assistance with ADLs. Please provide details about anticipated independence plan and date, if applicable.

Are you (the patient) taking any medications? (If hospital referral, please list medications that will be continued after discharge)

Do current medications include any of the following? (Select all that apply):

These medications may not be continued while in residential treatment.

Do you (the patient) have any special care needs? (select all that apply)

Please provide details for any special care need

Are you (the patient) pregnant?

Please provide your estimated due date or known trimester

Have you (the patient) been convicted of a sex related offense or arson?

Substance use

Rows	Method of Use	Last Date of Use	Frequency of Use (Daily, Weekly, etc...)
Alcohol
Opioids (Fentanyl, Heroin, etc...)
Benzodiazepines (Ativan, Xanax, etc...)
Meth/Amphetamines
Cocaine/Crack
Other

If “Other” please specify:

Option to upload an ROI and collateral documents. Please upload an ROI and any additional relevant information you would like us to review. Without an ROI we will be unable to contact you further about this referral. If you do not have records at this time. You can send them to us when you have them at Fax# 503-535-1163 or Referrals@forahealth.org)

I, (the patient), acknowledge the following treatment parameters:I will have a roommate I will be unable to use tobacco products I will be asked to keep a schedule of groups, individual therapy, meals and chores I will be unable to have visitors for the first 30 days (exception for DHS visits) I will have limited access to my cell phone

Additional program information can be reviewed here

By signing below, I certify, understand, acknowledge and/or agree that:

Submission of this form does not create a patient-provider relationship with Fora Health and does not guarantee that I will receive treatment by Fora Health.
Receipt of treatment by Fora Health is subject to availability and Fora Health has the sole discretion to determine whether Fora Health may or may not provide treatment to me.
Prior to receiving treatment, Fora Health will conduct a detailed assessment and intake to determine whether to provide treatment to me.
Fora Health is committed to maintaining the confidentiality of information on this form in compliance with applicable law and that I have reviewed Fora Health’s Notice of Privacy Practices located here.
I am authorized to share information on this form with Fora Health and consent to Fora Health’s use and disclosure of the information on this form to help facilitate my care.
To the best of my knowledge, information on this form is true, correct, accurate and complete and that false or misleading information may result in my disqualification from treatment or legal consequences.

Acknowledgement of treatment parameters, exclusionary criteria and info needed.

Residential Interest Form

Community Partner Referral

Contact information for person making referral