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Referral Form For

SUBSTANCE ABUSE SERVICES

Please fill out the following form

Date

Client Name

Gender

Martial Status

SSN

Date of Birth

Age

Race

Medical Assistance or M Number#

Legal Guardian

Full Address

Phone

Alternate Phone

Referring Agency | Address

Current School

Address

Phone Number

Activities Of Daily Living

Anger/ Temper/ Confict Resolution

Assertiveness/Self-esteem

Community Activity

Family / Natural Supports

Finances

Home/Housing

Self Care Skills

Safety to Self/Others

School Performance

Sexual Issues

Social Skills/ Peer Interaction

Substance Abue Issues

Coping Skills

Trauma

Medication Compliance Skills

Counselor Collaboration

Last Collaboration Date

Last Counseling Session Date

Vocational Skills

Leisure Skills

Work/Job Peformance

Legal Issues

Money Management

Dietary/Food Preperation

Crisis Management Skills

Physical Health

Other

Diagnosis given by

Diagnosis

Medications:

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#

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