Supplemental Documents
For documents submitted after a self-pay request or a Fitness for Duty referral was filed. For security, please do not email documents to individual CDTC staff.
Acknowledgment
*
I confirm that I have the documents ready to upload with this form, to allow the referral to be processed.
Which referral are these documents for?
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A self-pay evaluation or treatment request
A Fitness for Duty referral
Name of the person the referral is about
*
First Name
Last Name
Organization, if this is an employer referral
Name of the person uploading the documents
*
First Name
Last Name
Email of the person uploading the documents
*
Comments
Optional. What the documents are, or anything the office should know.
Upload the documents
*
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Certification
*
I certify that all information I provide on this form is accurate to the best of my knowledge.
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