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VOA Mid-States Recovery Referral Form

VOA Mid-States Recovery Referral Form

HIPAA

Compliance

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    If this is a life-threatening emergency, please leave this form and dial 911 or go to your nearest emergency room. 


    Who can submit a referral: Anyone who is seeking Addiction Recovery Services from VOA Mid-States. Please note that we cannot accept referrals from one family member on behalf of another.


    Important Note: Fill out this form to the best of your ability. If you need accommodations for language visual impairment to submit a referral please contact us at (502) 635-4530. 


    Instructions:

    1. Fill in the free-type boxes with relevant information and skip over any information boxes that do not apply to you.
    2. Continue to the next page by clicking “NEXT” located on the blue bar across the bottom of the bounding box.
    3. Right-Click to download any of the slide images you would like to keep for reference.
    4. When you are finished click “SUBMIT” located on the blue bar of the final bounding box.
    5. You must at least provide a client name, contact info and the program they are being referred to.

     

    Please allow 24 business hours for a follow up from our staff. 

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    Volunteers of America Mid-States is required to provide a Notice of Privacy Practices for the health information we collect and maintain throughout the duration of the services provided. The Notice of Privacy Practices describes how your information may be used and how you can get access to your information.
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    • Family member
    • Lawyer
    • Caseworker
    • Medical Professional
    • Housing Professional
    • Other
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    Information for the person filling out the form on behalf of someone else.
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    The person who is seeking treatment. **You MUST provide a phone number or email in order for us to contact you about the status of your referral.**
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    Please Select
    • Please Select
    • Medicaid
    • Medicare
    • Commercial
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    Please Select
    • Please Select
    • Single
    • Married
    • Divorced
    • Separated
    • Widowed
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    Please explain.
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    Guardianship is a legal relationship between a court-appointed adult and the individual. This individual is usually declared disabled by the court and is no longer able to care for their personal/financial needs.
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    -
    Pick a Date
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    Please fill out all fields for any substance listed
    1 of 10
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    check all that apply
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    • Huge
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    quoteCreated with Sketch.
    Ok
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    Has the individual given birth in the last 12 months?
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    If you chose other please list and explain the medical condition(s) not listed.
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    If you chose other please list and explain the mental health condition(s) not listed.
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    (within the last year)
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    (Suboxone, Subutex, Vivitrol, Methadone, etc.)
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    (Suboxone, Subutex, Vivitrol, Methadone, etc.)
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    *** NOTICE ***

    Medications not permitted: opiates, amphetamines, and benzodiazepines. Gabapentin may be approved by the medical team on a case-by-case basis. 

     

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    Does the individual seeking services have children?
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    You previously answered yes to this question. Please provide further information below.
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    Date involvement began and why:
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    Please provide the date P&P started and PO name and number.
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    -
    Pick a Date
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    Please explain (when/where).
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    Please check all that apply
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    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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VOA Mid-States Recovery Referral Form
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