REFERRING INFORMATION
Who are you completing this form for?
*
Please Select
Someone else
Myself
Agency/Organization
*
Please Select
Armada Recovery
Broadway Recovery Services
Canfield Healthcare Center
Generations Behavioral Health
Hope House
ImpacTherapeutics
Lifepoint Health
Mercy St. Elizabeth - Boardman
Mercy St. Elizabeth - Youngstown
Midwest Recovery Services
OnDemand
Recovery First
Robin Recovery
Solero Behavioral Health
Small Steps
Team Recovery
Other - Not in List
How Did You Hear About Us?
*
Please Select
Google
Facebook
Instagram
Friend/Family Member
A Healthcare Provider
Other
Other Agency or Organization
*
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Requested Services - SELECT ALL THAT APPLY
*
MAT: Medication Assisted Treatment (Suboxone, Sublocade, Subutex, Vivitrol)
PHP: Partial Hospitalization Program - Substance Abuse
PHP: Partial Hospitalization Program - Mental Health
IOP: Intensive Outpatient Program - Substance Abuse
IOP: Intensive Outpatient Program - Mental Health
OP: Outpatient Counseling Only
Spravoto Treatment
Medication Management for Psychiatric Medications
Mental Health Day Treatment
Peer Support
Recovery Housing (through one of our housing partners)
Other
What Services Are You Interested In - SELECT ALL THAT APPLY
*
MAT: Medication Assisted Treatment (Suboxone, Sublocade, Subutex,Vivitrol)
PHP: Partial Hospitalization Program
IOP: Intensive Outpatient Program
OP: Outpatient Counseling Only
Spravoto Treatment
Medication Management for Psychiatric Medications
Mental Health Day Treatment
Peer Support
Recovery Housing (through one of our housing partners)
Other
CLIENT CONTACT INFORMATION
Name
*
First Name
Last Name
Does the client have any of the following?
*
Phone Number
Email Address
Is the Client Currently Inpatient?
*
Please Select
Yes
No
Anticipated Date of Discharge
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security #
If known, please provide for insurance verifications
Contact Number
Format: (000) 000-0000.
Email
If known, please provide for consent paperwork to be sent virtually
Sex
*
Male
Female
Trans Male
Trans Female
Non-binary
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the individual have any criminal history for violent offenses?
*
Please Select
Yes
No
Explain - history of violent offenses
*
Has the client ever been charged with arson?
*
Please Select
Yes
No
Explain - arson history
Is the client a registered sex offender in ANY state?
*
Please Select
Yes
No
Explain - sex offender history
Has the client ever been hospitalized for their mental health?
*
Please Select
Yes
No
Mental Health Hospitalization History
*
Is the client currently taking any medications?
*
Please Select
Yes
No
Medication List
*
Insurance
*
Please Select
Medicaid
Commercial
Medicare
Uninsured
Unsure/Unknown
Insurance ID
What Medicaid Provider?
*
Please Select
AmeriHealth
Anthem
Buckeye
CareSource
Humana
Molina
United Healthcare
I don't know/Unsure
Insurance Card
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