Universal Referral Form

COVID-19 Resources

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- About Us
Stigma Reduction Education
Services
- Referral Form
- COVID19 Resources

Lighthouse Recovery Community Center

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

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

Contact

Office (920) 374-4433
HOTLINE (920) 374-3989
Lrccdirector@gmail.com
721 Park Street, Manitowoc, WI 54220
9am - 5pm

Facebook-f

Instagram

Name

Message

COVID19 Alert

Due to COVID-19, in following the recommendations of the Health Department, the Lighthouse Recovery Community Center may have periods of closure. For access to online meetings, check out our Facebook page. If you need further assistance, contact your Recovery Coach or call the Hotline 920-374-3989. Stay safe!

Universal Referral Form

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