1258 High Street, Eugene, OR 97401
Phone 541-342-8437 | Fax 541-242-2999
Medication Assisted 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:
