Referral Checklist for PHP/IOP

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Email *

Name *

Date of Birth

YYYY

Phone Number

Primary Diagnosis Substance Use Disorder

Yes

Clear selection

Please List Substances of Choice in Order of Preference

Medically Stable (No need for inpatient care, no acute benzo/alcohol withdrawal symptoms, no need for detox)

Yes

Clear selection

Co-occurring Mental Health Issues

Any additional Medical Conditions we should be aware of:

Referring Party (name/practice name, relationship, phone number, email)

Any other services that Mayrx can assist with? We offer MAT/MH Medication Management, Peer Suport Services, Individual Therapy, and DWI Services

Which service are you looking for?

Partial Hospitalization (proceed to Section 2)

Intensive Outpatient (proceed to Section 3)

Outpatient Counseling/Therapy (please just submit form)

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