Medication Assisted Recovery Treatment Referral (External)


1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Medication Assisted Recovery Treatment Referral (External)

Referral for:

Individual Name:     Date of Birth:

Active contact information for referred individual:

Address:

Phone:     Email:

Okay to identify ourselves and/or leave a message?

Use above contact information when scheduling the placement screening?

          If no, who and how should we contact?

Referred by (name of person and entity):

Insurance Coverage:

          If Commercial Insurance, enter name of Commercial Insurance:

Primary Language:

          If Other, enter Primary Language:

Interpreter Needed:

ROI signed for Referral Source (complete in addition to referral):

Date of discharge (if applicable):

Is treatment mandated?

          If yes, by whom:

Mental Health and/or Substance Use Diagnosis:

Substance Use History:

History of or currently receiving methadone treatment:

          If current, name of prescriber (if none, enter “none”):  

History of Suboxone use:

          If current, name of prescriber (if none, enter “none”):  

History of violent or aggressive behavior:

Please describe “yes” answers above:

Current Medications (name, dose, interval, indication):

Current Allergies to Medications:


Leave this empty:

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Document name: Medication Assisted Recovery Treatment Referral (External)
lock iconUnique Document ID: d60750b78063411be63616aea061602cbb3e2dcc
Timestamp Audit
September 17, 2021 3:51 pm PDTMedication Assisted Recovery Treatment Referral (External) Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
September 20, 2021 8:16 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
September 29, 2021 10:00 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
September 29, 2021 10:33 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
October 5, 2021 9:28 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 98.232.224.39
October 5, 2021 9:28 am PDTCFD Referrals - referral@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 98.232.224.39
October 7, 2021 12:38 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
October 7, 2021 12:38 pm PDTCFD Referrals - referral@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
October 14, 2021 4:00 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
October 14, 2021 4:00 pm PDTCFD Referrals - referral@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
October 18, 2021 9:30 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
October 18, 2021 9:30 am PDTCFD Referrals - referral@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202