Universal Referral Form Consumer/Service Recipient Name Telephone Secondary Form of Contact Date of Birth Gender Female Male Other Would rather not disclose Address County of Residence Case Number Diagnosis Has there been a primary or co-occurring opioid use disorder in recipient's history? Yes No Service Facilitator/Social Worker Name Telephone Email Has the recipient survived an opioid overdose within the last 6 months? Yes No Arrested or incarcerated for a drug related offense within the last 6 months? Yes No Service Requested (Choose all that apply) Peer Support Individual Skill Development and Enhancement Individual and/or Family Psychoeducation Wellness Management and Recovery Employment Related Skills Training Medication Assisted Treatment(Vivitrol) Family Recovery Support and Education Please note any requests for specific provider(s) The following materials have been included with this referral CCS Service Authorization CCS ISP CCS Assessment Grant Intake Form Submit
