Lauren's Wish Addiction Triage Center Referral Form

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Lauren’s Wish Addiction Triage Center Referral Form

Please complete the referral form on this page and a member of our team will reach out to you shortly.

For a copy of our paper referral, CLICK HERE

You can also submit a referral through our new FAMILY PORTAL, by CLICKING HERE! Registering is fast and easy!

referrals@laurenswish.org

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Referral

Referral Source(Required)

Name of your facility

Referral Source Contact(Required)

Person making referral

Referral Source Address(Required)

Address of your facility

Referral Phone Number(Required)

Facility contact number

Referral Source Email(Required)

Email address of person making referral

Name of Person Being Referred(Required)

First and last name

Date of Birth(Required)

MM slash DD slash YYYY

Age

Gender(Required)

Forms of Identification

Birth Certificate

State ID/Drivers License

Social Security Card

Forms of ID the individual has

Social Security Number(Required)

Insurance Carrier(Required)

Name of Insurance provider, if none, use N/A

Insurance Policy Number(Required)

Policy number of insurance, if none, use N/A

Reason for Refferal(Required)

What type of treatment is the individual seeking?

Have referrals been sent to other facilities?(Required)

Name and Contact of Facilities where referrals have been sent

Name of facility and contact information of facilities where referrals have been submitted

Medical Conditions

Diabetes

COPD

Hypertension/Hypotension

Seizures

MRSA

Asthma

Hepatitis A/B/C

HIV

STI

Cardiovascular issues

Open Wounds/Burns

Please select all that apply

Do you require any medical equipment or mobility devices?

Oxygen

Wounds Vac

CPAP

Walker

Wheelchair

Cane

Check all that apply

In the last 10 days, have you tested positive for:

COVID

Flu

List of Current Medications and Dosage(Required)

Please list all current medications and dosages, if none, use N/A

Have you ever attempted suicide?(Required)

Please list dates of attempt and method

To the best of your ability, please list dates and methods

Date of last use(Required)

MM slash DD slash YYYY

Date you last used a substance or alcohol

Substance(s) last used

Benzodiazepines (valium, xanax, ativan, etc.)

Alcohol

Marijuana

Cocaine

Crack Cocaine

Heroin

Fentanyl

Prescription Opiates

Amphetamines/Methamphetamines

Inhalants

Methadone (prescribed)

Methadone (unprescribed)

Suboxone/Subutex (prescribed)

Suboxone/Subutex (unprescribed)

Select all that apply

Are you a registered sex offender?(Required)

Do you have any prior criminal charges?(Required)

Please list past charges

List past charges to the best of your ability

Do you have any pending criminal charges?(Required)

Please list pending charges

List pending charges to the best of your ability

Are you on probation or parole?(Required)

Name, Number and County of Probation/Parole Officer

Δ

Together we will help those suffering from addiction.

Home
In Memory of Lauren Renee Cole
Facts About Fentanyl
Board of Directors
Contact Us
Testimonials
Donation

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