Addiction Counseling Specialist Referral Form

Client Full Name

First NameLast Name

Date of Birth

Date

Client Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Client Email Address

example@example.com

Client Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Referral Source (Your Name and Organization)

Relationship to Client

Presenting Concerns (briefly describe the addiction or related issues)

Urgency of Referral

Preferred Contact Method for Client

Has the client previously received counseling for addiction?

Current Support Systems (select all that apply)

Preferred Appointment Date/Time (if any)

Date

Hour MinutesAM/PM Option

Additional Notes or Relevant Information