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
ImpacTherapeutics
Lifepoint Health
Mercy St. Elizabeth - Boardman
Mercy St. Elizabeth - Youngstown
Midwest Recovery Services
OnDemand
Recovery First
Robin Recovery
Solera 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
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
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
Date
Date of Birth
*
/
Month
/
Day
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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