Self Referral Form Interested in our program ? Fill out some info and we will be in touch shortly! We can't wait to hear from you. Please complete to start our approval process: * First Name Last Name Email * Phone * If you don't have a phone, please put 000-000-0000 (###) ### #### Date of Birth * MM DD YYYY Social Security Number Gender Identity Male Female Prefer Not To Answer How many days have you used in the past 30 days? Daily 1-3 times a week 1-3 times a month N/A How often have you used IV drugs in the past 30 days? Always Sometimes Never What substances have you used in the past 30 days? Check all that apply Alcohol Opiates(oxy, heroin, fentanyl, pain pills, morphine, etc.) Methamphetamines or Amphetamines Benzos Cocaine or Crack Marijuana Other- Please explain below Please explain other: Are you experiencing withdrawal symptoms? Yes No Please list any medical concerns: Are you Pregnant? Yes No Are you currently on any medications? Are you taking medications as they are prescribed? Yes No Please list any mental health diagnoses: In the past 30 days, how many times have you been arrested? Number of lifetime detoxification admissions: Is someone telling you that you must complete treatment? No- I am referring myself Court Child Protective Services My Probation or Parole Officer My Family Work or School I am on commitment Other- Please explain below Name of Probation Officer/Parole Officer or County of Court referring you: Only if Applicable Please Explain Other: Describe your living environment Homeless- No fixed address (includes shelters) Dependent living- Dependent children and/or adults living in a supervised setting Independent living- including on own, self supported, and non-supervised group homes Children living with their family Do you have medical insurance? Yes No- I need help applying No- I already applied If you have health insurance, who is your insurance provider? If you know your MA number, Please provide it Do you require any special accomodations? Yes No If yes, please describe: How did you find out about our services? Family or Friend Social Media Internet Search Community Event Brochure or Flyer Referral from Another Organization Advertisement (Radio, Newspaper) School and Educational Institution Email Announcement Other Thank you for your referral, we will be in touch soon!
