RESADA Outpatient Services Clinical Referral

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Complete clinical referral for screening and program follow-up. Submission does not guarantee admission or services. Call 719-456-2600 for urgent coordination. Call 911 for a medical or safety emergency.

Referral date *

YYYY

Referral agency or organization *

Referral contact name and title *

Referral contact phone number *

Referral contact email address *

Relationship to the person being referred *

Self

Family or support person

Probation or parole

DHS or child welfare

Hospital or healthcare provider

Behavioral health provider

Court or judicial agency

Other

Is a release of information available or being requested?

Yes

Not applicable

Unknown

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