Recovery Program Referral (External)


1258 High Street, Eugene, OR 97401

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

Recovery Program 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:

History of Suboxone use:

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: Recovery Program Referral (External)
lock iconUnique Document ID: 1bc47a29ef4ed0230ae1cd8796e9101936f0e583
Timestamp Audit
April 26, 2021 9:02 am PSTRecovery Program Referral (External) Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
April 26, 2021 10:12 am PSTCFD 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
April 26, 2021 10:59 am PSTCFD 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
April 26, 2021 11:06 am PSTCFD 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
May 3, 2021 8:18 am PSTCFD 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
August 17, 2021 1:50 pm PSTCFD Main - 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
September 17, 2021 4:20 pm PSTCFD Main - 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
February 23, 2022 8:41 am PSTCFD 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
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