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Referring Agency Office Information

Referred Client/Patient Information

Insurance

Reason For Referral

Primary Mental Health Diagnosis

Your Referral has been submitted, thank you.

Medical Diagnosis (if applicable)

Drug Addiction

Has Client tried to quit using a substance?

Is Client active in his/her addiction?

Does Client smoke cigarettes?

Does Client drink alcohol?

Is there a history of Suicide/homicide Ideation?

Court Involvement

Other Agency Involvement

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