Referral Form

Client Information

Client Name*

Home Phone

Current Address*

Street Address Address Line 2 City State ZIP Code

Birth Date*

Social Security #

Medicaid*

Yes
No

Medicaid #

Referral Information

Therapist name & credentials

Therapist Address

Street Address Address Line 2 City State ZIP Code

Therapist email

Therapist phone

Client Diagnosis

Choose one

296.20-296.36 Major Depressive Disorder
295.90 Schizophrenia Disorder
296.41-296.44 Bipolar Disorder
Attention-Deficit/Hyperactivity Disorder (ADHD)
Conduct Disorder
Obsessive-Compulisve and Related Disorders
Posttraumatic Stress Disorder (PTSD)

AXIS I

AXIS II

AXIS III

AXIS IV

AXIS V

This diagnosis was given by

Diagnoses date:

State the need for PRP services

Check all that apply

Is this a self referral?

Yes
No

Do you have an attorney?

Yes
No

Are you on probation?

Yes
No

Probation Agents Name

Probation Agents Phone number

Date of last arrest?

Date of next court hearing?

Is your driver’s license currently valid?

Yes
No

Referral Name & Title

Referring workers phone

Referring workers fax number

Email

Client Treatment Information

Drug of Choice

Last Used ?

How Often

How Much

Withdrawal Symptoms?

Yes
No

Longest Period of Abstinence

Military History

Branch of Military

Tours of Duty

Number of Arrests in last 30 days

Number of Arrests in Last 12 mos

Number of Dependent Children

Physical Disabilities

Medical Challenges

Education Level

Grade school
HS/GED
College

Recommended Services

Education Level

Substance Abuse Evaluation-Consists of one 2hr. session.
Outpatient Treatment - 12-18 week program (6-8 hours per week) for adults. Random Drug Testing, individual, group, and self-help meeting attendance is required.
Intensive Outpatient–12-24 week intensive program (9-12 hours per week) for adults. Individual, group, and self-help meeting attendance is required. Random Drug Testing required.

Apex Referral Form

Step 1 of 3

Which Program(s)?

Client Information

Referral Information

Client Diagnosis

State the need for PRP services

Client Treatment Information

Recommended Services

Signature

Form Instructions:

Contact

Call

Email

Address

Hours