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Methadone Addiction
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Referral Form

Patient Information

Full Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Phone Number(Required)

Current Location (Home / Hospital / Facility)(Required)

Insurance Information

Insurance Provider(Required)

Plan Type(Required)

PPO

HMO

Medicaid

Other

Policy #(Required)

Group #(Required)

Subscriber Name(Required)

Subscriber DOB(Required)

Reason for Referral

Untitled(Required)

Detox (ASAM 3.7)

Residential Treatment (ASAM 3.5)

Mental Health

Substance Abuse

Co-Occurring Disorders

Primary Concern(Required)

Substance Use History

Primary Substance(s)(Required)

Frequency of Use(Required)

Last Use(Required)

Route of Use(Required)

Withdrawal Symptoms (if any)(Required)

Previous Treatment (Detox/Residential/IOP)

Mental Health Information

Current/Past Diagnoses(Required)

Current Symptoms(Required)

History of Self-Harm(Required)

Yes

No

Suicidal Ideation(Required)

Yes

No

Homicidal Ideation(Required)

Yes

No

Medical Information

Current Medical Conditions(Required)

Current Medications(Required)

Allergies(Required)

Clinical Risk & Stability(Required)

Medically Stable

Requires Detox Monitoring

Behavioral Concerns

Unable to function independently

Unstable living environment

Referring Provider Information

Name(Required)

Organization(Required)

Phone(Required)

Email(Required)

Date of Referral

MM slash DD slash YYYY

Note: All referrals are subject to clinical pre-screening, ASAM criteria review, and insurance verification prior to admission.

1125 Strong Road, Quincy, FL 32351
(888) 782-3342
contact@sojournwellness.health
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1125 Strong Road, Quincy, FL 32351
(888) 782-3342
contact@sojournwellness.health
Privacy Policy
Terms & Conditions