Medication Assisted Recovery Treatment Referral (External)
Referral for: Medication onlyMedication with recovery program services
Individual Name: Date of Birth:
Active contact information for referred individual:
Address:
Phone: Email:
Okay to identify ourselves and/or leave a message? YesNo
Use above contact information when scheduling the placement screening? YesNo
If no, who and how should we contact?
Referred by (name of person and entity):
Insurance Coverage: None OHP Commercial Insurance
If Commercial Insurance, enter name of Commercial Insurance:
Primary Language: EnglishSpanishOther
If Other, enter Primary Language:
Interpreter Needed: YesNo
ROI signed for Referral Source (complete in addition to referral): YesNo
Date of discharge (if applicable): Not Applicable
Is treatment mandated? YesNo
If yes, by whom:
Mental Health and/or Substance Use Diagnosis:
Substance Use History:
History of or currently receiving methadone treatment: CurrentPastNever
If current, name of prescriber (if none, enter “none”):
History of Suboxone use: CurrentPastNever
History of violent or aggressive behavior: YesNo
Please describe “yes” answers above:
Current Medications (name, dose, interval, indication):
Current Allergies to Medications:
Leave this empty:
Your legal name
Your email address
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Document Name: Medication Assisted Recovery Treatment Referral (External)
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