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+1 (800) 414- 8250

Referral Form For

SUBSTANCE ABUSE SERVICES

Please fill out the following form

Date

Client Name

Gender

Marital Status

SSN

Date of Birth

Age

Race

Medical Assisstance or M Number#

Legal Guardian

Full Address

Phone Number

Alternate Phone Number

Referring Agency l Address

Current School

Address

Phone Number

Choose Clients Needs

Acts of Daily Living

Anger

Assertiveness

Community Acitivity

Family

Finances

Home

Self-Care

Choose Clients Needs

Safety to Self/Others

School Performance

Sexual Issues

Social Skills/Peer Interaction

Substance Abuse Issues

Coping Skills

Trauma

Medication Compliance Skills

Choose Clients Needs

Vocational Skills

Leisure Skills

Work/Job Performance

Legal Issues

Money Management

Dietary/Food Preparation

Crisis Management Skills

Physical Health

Other

Counselor Collaboration

Last Collaboration Date

Last Collaboration Session Date

Diagnosis Given By

Diagnosis

Medications * Required

No

Yes

If Yes, please list

Continuation of Services Agreement:

I, (Counselor Name and Title) am agreeing to a continuation of Substance Abuse Services for the above-mentioned client.

I am completing this form

I give verbal consent for EM to complete this form

I am emailing this form

Referring Counselor (title and credentials):

Phone#

Empowering Mindz Information

Thanks for submitting!

583 Frederick Rd Suite A, B, & C

Catonsville, MD. 21228

Phone (443) 341.6332 l Toll Free Number +1 (800) 414.8250 l

©2024 by Empowering Mindz.

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