Substance abuse referral form 2026

1. Click ‘Get Form’ to open the substance abuse referral form in the editor.
2. Begin by filling in the 'Receiving Facility' and 'Referring Facility' sections with the appropriate names.
3. Enter the 'Date of Referral' and the 'Name of Service Recipient' to identify the individual being referred.
4. Complete the 'Social Security Number', 'Date of Birth', and any relevant charges, including 'Docket #' if applicable.
5. If applicable, indicate DCS custody status for juveniles and provide details about the alleged crime dates and current location.
6. Fill in clinical information, listing all interventions used to prevent referral, including any psychological testing or medication adjustments.
7. Clearly specify the reason for referral to an inpatient facility, ensuring not to state it as 'For Forensic Evaluation'.
8. Document current medications and medical concerns, along with previous mental health treatment history.
9. Finally, ensure all necessary information is included in the checklist at the bottom of the form before submitting.

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