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.
1.
Date of Referral
*
mm/dd/yyyy
2.
Name of Referred Individual:
*
3.
Medical Assistance Number if Applicable:
*
If you do not have Medical Assistance please type "N/A".
4.
Please Provide Your Insurance Information.
If you do not have insurance please type "None" in the Insurance name box.
Insurance Company Name
Policy Holder's Name
Policy Number
Group Number
Insurance Information
5.
Please complete the following information:
*
Age:
Identified Gender:
Date of Birth:
Social Security Number
6.
Please enter the demographic information:
Street Address:
City:
State:
Zip:
County:
Phone(Home):
Phone(Work):
Phone(Cell):
Legal Guardian Name (if applicable):
7.
Marital Status:
Marital Status:
Single
Married
Divorced
8.
Family Doctor:
9.
Referral Source:
*
If you are referring yourself please type "self".
Referral Source(Name/Agency):
10.
Is the applicant currently receiving services?
Is the applicant currently receiving services?
Yes
No
11.
If the applicant is receiving services please list the Agency Name and Service:
If you are not currently receiving services type N/A.
Agency:
Service:
12.
Please List Areas for Improvement:
13.
Vocational/Education(check all that apply):
Employed
Unemployed
School
14.
School Information
If this does not apply to you please type N/A under School Name.
School Name:
Grade:
Do you have an IEP (Y/N):