Substance Use Disorder (SUD) Referral Form

 

"*" indicates required fields

Date*
Address
Date of Birth*

Last Used ?*
Route of Administration*
Withdrawal Symptoms?*
Tobacco use in last 30 days?*
Have you participated in medication assisted treatment?*

If Yes.... please complete the next two sections

Medications

Marital Status*
Education Level*
Employment Status*
   

Recommended Services

Education Level*

Terms

Referral Authorizations

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Restoration Behavioral Health Systems. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to Restoration Behavioral Health Systems. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to Restoration Behavioral Health Systems. I authorize payment of medical benefits to David’s Lost Clinical Services. I also understand that payment of is my responsibility and Restoration Behavioral Health Systems has the right to use any means necessary to collect fees to include submission of my name and other information to a collection agency for the purposes of fee collection.

Typing my name below serves as my digital signature.

Referral Authorizations*
This field is for validation purposes and should be left unchanged.