Referral - Revive Inc.

Referralangela2023-10-23T11:31:41-05:00

Download Referral Form PDF

Referral Form for Revive Services
Which program are you interested in completing a referral for? *
Aftercare/Continuing Care
Alcohol/Other Drug Education
Free Christ-Centered 12-Step Program
Traditional Intensive Outpatient
Outpatient Treatment
Relapse Prevention Outpatient Program
Juvenile Intensive Outpatient
Unity Houses
Life Skills
Individual Counseling
Evaluations
How did you hear about Revive? *
Radio Station
Revive Website
Facebook
Family/Friends
Other (please list)
source_other
First Name *
Last Name *
Age *
Sex/Gender *
Gender/sex as identified on driver’s license or ID
Male
Female
Phone *
Email *
Street Address *
City *
County *
State *
Zip Code *
Do you have a legal guardian? *
Yes
No
Are you a veteran? *
Yes
No
Are you a US Citizen? *
Yes
No
Reason for Referral: *
Do you use any substances? *
Yes
No
Provide some information about your substance use
Have you been exposed to any infectious diseases in the past two weeks like Covid, Chicken Pox, Shingles, MRSA, Lice, Mumps, Measles, Bed Bugs, Hepatitis, AIDS/HIV, Tuberculosis? *
Yes
No
Please explain your exposure:
Do you have any current health issues? *
Yes
No
Explain current health issues:
Do you take any medications? *
Yes
No
Please provide name and dosage or bring list to your first appointment.
Have you ever been placed on a Mental Health Board Commitment? *
Yes
No
When and what county?
Have you (or anyone on your behalf) applied for Medicaid/Medicare? This includes other medical offices, caseworker, etc. *
Yes
No
Please provide Medicaid/Medicare number:
Do you have any Insurance? *
Yes
No
Name of Insurance Company
Insurance Company Phone Number
Insurance Company Policy Number
A copy of your insurance, Medicaid, or Medicare card will be needed at the time of your appointment. To provide this information ahead of time, you can email a copy of your card (front and back) to info@reviveinc.org.

What is best time of day to call you to set up an appointment? We will make every attempt to call you the next business day. Thank you for your interest in Revive. *
Thank you for your referral. It has been sent. We will make every attempt to call you the next business day.
There was an error trying to send your message. Please try again later.

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