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Thrive! Referral Form
Please use this form when requesting Family Peer Recovery Services for yourself or as a referent. Responses to this form will be sent to the email thrivefs2911@gmail.com
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Concerned Person's First Name
*
Your answer
Concerned Person's Last Name
*
Your answer
Street Address
Your answer
City:
*
Your answer
State:
*
Your answer
Zip Code:
*
Your answer
Concerned person's cell phone (for follow-up):
*
Your answer
Concerned person's email (for follow-up):
Your answer
Name of loved one using substances:
Your answer
Age of loved one using substances:
*
Your answer
Relationship to loved one using substances:
*
Parent
Partner
Grandparent
Sibling
Child
Other
My loved one identifies as:
LGBTQIA+
Hispanic
Native American
East African
Black
Clear selection
Loved one's Insurance: (list private and name, state Medicaid, or no insurance)
*
Your answer
Substance(s) used or addiction(s):
*
Your answer
Length of use:
Your answer
Briefly Describe your situation
Your answer
I would like a family peer specialist to contact me
*
Yes
No
Best Way to Contact Me
*
Text Message
Email Address
Phone Call
Best Time to Contact Me
Morning
Afternoon
Evening
Anytime
Clear selection
How did you hear about Thrive?
*
Facebook
Better Boundaries Workshop
Small Changes, Big Results Workshop
Friend
Community Event
Pam Lanhart
Dakota County Contact
If "Other" above - please note your referral source
Your answer
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