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REN Self Referral Form
Recovery Empowerment Networks Self Referral Form
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* Indicates required question
Recovery Goal
*
Your answer
First and Last Name
*
Your answer
Preferred Name (Optional)
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
AHCCCS ID
*
Your answer
Guardian Name
Your answer
Guardian Phone Number and Email
Your answer
Address
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Clinic Name
Your answer
Clinic Representative Name and Title
Your answer
Clinic Phone Number and Email
Your answer
Are you currently on probation/parole?
*
Yes
No
If "YES" probation/parole officer Name, Phone Number, and Email
Your answer
Do you authorize REN to share your medical information with your probation/parole officer?
Yes
No
Clear selection
Are you a registered Sex Offender?
*
Yes
No
Is this Court ordered treatment?
*
Yes
No
Are you Represented by an advocate from the office of human rights?
*
Yes
No
If "YES" Advocate Name, Phone Number, and Email
Your answer
Gender Identity
*
Women
Man
Transgender Male
Transgender Female
Non-Binary
Other
Psychiatric Diagnosis (DSM V)
*
Major Depressive Disorder
Bipolar Disorder
Schizophrenia
Generalized Anxiety Disorder
Schizoaffective
Substance Use
Other
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