Referral Form for Mental Health and Drug and Alcohol Services

 
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 Information 

 
  Welcome! Thank you for considering CenClear for your mental health or drug and alcohol treatment needs. This form will be used to refer you, or the person you are referring, for needed services. If you have any questions or need assistance completing this form please call us at 1-877-341-5845 ext. 2391.
No information about you or the person you are referring will be released without written consent. All of our services are confidential.
CenClear does not discriminate on any basis including a person's age, sex, color, race, disability, religious creed, lifestyle or source of payment.
   
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  Select Date
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If you do not have Medical Assistance please type "N/A".
 
   
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If you do not have insurance please type "None" in the Insurance name box.
 
     
Insurance Information    
   
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If you are referring yourself please type "self".
 

 
   
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If you are not currently receiving services type N/A.
 

 

 
   
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If this does not apply to you please type N/A under School Name.
 

 

 

 
   
 
 
 
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