Self Referal Form 
Please fill out as thoroughly as possible, all information is used to assess appropriate placement and you must leave a call back number in order to be considered for placement. All information is kept confidential and secure. 
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Name 
Call back number and Email 
Medicaid Insurance Provider 
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Type of placement seeking 
Sex at birth 
Identify as 
Age  *
Social Security Number 
Date of Birth 
MM
/
DD
/
YYYY
Are you currently in treatment? 
If leaving treatment I am discharging .. 
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Last date of use of any substance, what was used 
Drug of Choice 
On arrival, will you be able to provide a negative drug screen ? 
Mental Health Diagnosis 
Have you had any thoughts to harm yourself or anyone else in the past 30 days? 
Have you ever been hospitalized for your mental health or for suicidal ideation? 
Current Medications 
IF on Suboxone, Are you willing to transition to strips? 
Medical Conditions/Concerns
Are there any other medical barriers that would keep you from participating in treatment? 
Are you able to perform ADL's like feed yourself, bathe yourself, get in and out of a shower on your own? 
Are you able to safely walk up or down stairs?  
Are you able to walk at least 1-2 miles? 
Are there any other physical barriers that would keep you from participating in treatment? 
Are you currently under supervision from any of the following? 
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IF yes - what county? supervising officer, case worker or attorney? contact information for them? 
Do you have any upcoming court dates? 
Are you a registered sex offender? 
Do you understand this is not just a sober living, this is supportive recovery ousing for thse particvipating in clinical services. It is required to participate in your IOP or TRP Classes, Therapy, Case Management Services and Peer Support Groups? 
Do you understand and agree to a Minimum of 7 days  property restriction on arrivial? 
Do you understand and agree to parfticipate in a 12 Step Fellowship like AA or NA? 
Do you understand and agree that you cannot work for the first 14 days and that you must have a sponsor before being able to go to work? 
Do you understand and agree that all outside appointments and commitments MUST be arranged around your program schedule and class times? 
Is there any other information that you feel needs to be known? 
Do you confirm that all information given is true and accurate, to the best of your knowledge? 
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