Referral Form

Drug/Alcohol Information

Personal Information

If yes, please complete below.

Who could we contact in case we are having a hard time connecting with you?

Living Arrangements

Current Providers: Please list the name, clinic, and phone number for each provider.


Referent

If you are referring someone, please enter your information below.


Signature

I understand that by submitting this form I will be contacted to further discuss my request for services to see if my needs can be met by The Human Service Center. Further I understand that if staff are not able to reach me directly, they have my permission to contact the person listed above as my contact.

I further understand that participation in any of these services is voluntary and requires a commitment. It will require attending appointments, completing any assignments, and completing documentation that is part of the service programs.

Typing your name here means you accept the statement above.