Teen Residential Program Referral
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  • Teen's Information

    Please provide the following information for teen.
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  • Other Substances Used/Misused
  • Past hospitalizations and recent treatment history.

    Please include both inpatient, outpatient, community based and reason for referral to level of care.
  • Place and date of service
    Type of service
    Reason for admission
    Comments Regarding completion and/or effectiveness
  • Place and date of service
    Type of service
    Reason for admission
    Comments Regarding completion and/or effectiveness
  • Place and date of service
    Type of service
    Reason for admission
    Comments Regarding completion and/or effectiveness
  • Place and date of service
    Type of service
    Reason for admission
    Comments Regarding completion and/or effectiveness
  • Place and date of service
    Type of service
    Reason for admission
    Comments Regarding completion and/or effectiveness
  • A minimal 30-day supply of medications must be provided by the family at time of admission or the teen may not be admitted to the program.
  • Legal History

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  • School History

  • Referral Information

    Contact information of referring agency.
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  • Insurance Information

    Copy of insurance card must be presented at time of screening, however you may attach a copy to the referral form as well.
  • Required Items/Documents for Admission

    Please note that the following items are required for admission. Upload as many as you have.