Referral Form for Revive Services

Which program are you interested in completing a referral for? *
How did you hear about Revive? *
Sex/Gender *
Gender/sex as identified on driver’s license or ID
Do you have a legal guardian? *
Are you a veteran? *
Are you a US Citizen? *
Do you use any substances? *
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? *
Do you have any current health issues? *
Do you take any medications? *
Have you ever been placed on a Mental Health Board Commitment? *
Have you (or anyone on your behalf) applied for Medicaid/Medicare? This includes other medical offices, caseworker, etc. *
Do you have any Insurance? *

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