1258 High Street, Eugene, OR 97401

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

Recovery Program Referral (External)

Referral for: AdultYouth

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:  English Spanish Other

          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: YesNo

History of Suboxone use: YesNo

History of violent or aggressive behavior: YesNo

Please describe “yes” answers above:

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

Current Allergies to Medications: