SACADA Treatment Referral

  • Referral for Treatment

  • Today's Date
     - -
  • Are you a San Antonio Council on Alcohol and Drug Awareness Employee*
  • Format: (000) 000-0000.

  • PERSON YOU ARE REFERRING

  • The Persons Date of Birth
     - -
  • Gender at Birth
  • Format: (000) 000-0000.
  • Is the individual currently serving in the military, or have they served in the military at any time in the past?
  • Marital Status
  • What is the persons living situation
  • Do you know what substances the person has used or is using currently?
  • Substances
  • Do you know if the person has insurance?*
  • Is the person involved with any to the following?*

  • When making a referral for treatment, please complete the SIBRT below as part of the process. 

     

  • Rows

  • Item responses on the CAGE questions are scored 0 for "no" and 1 for "yes" answers, with a higher score being an indication of alcohol problems. A total score of two or greater is considered clinically significant.

    The normal cutoff for the CAGE is two positive answers, however, it is recommended that staff lower the threshold to one positive answer to cover a wider range and identify more patients who may have substance abuse disorders.

  • Collateral information

    Please upload any documents or pictures of documents that are pertinent to the referral.

  • Please upload all documents for the referral

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