tx CLIENT REFERRAL FORM

Referral Form

 

All In Sober Living provides Freestanding Board and Lodge (FSB&L) housing

in the Twin Cities Area and Mankato for adults with a primary substance use disorder (SUD) diagnosis.

We offer a structured, supportive recovery environment with a community-based recovery integration.

 

Elligibility Criteria:

* Must be 18 years of age or older
* Must be enrolled in Medicaid
* Must have a primary diagnosis of Substance Use Disorder (SUD)
* Must require a stable, recovery-focused housing environment
* Must be engaged in a licensed outpatient program.
* Must achieve a score of 4 in Dimensions 4, 5, or 6 on the comprehensive assessment and be entered into DAANES accordingly.

 

 

 Please Click Next To Begin!

 

General

Client First name:
Client first name
Client Middle name:
Client middle name
Client Last name:
Client last name
Client Date of birth:
Client birthdate
Client Gender:
Client gender

Contact Information

Client Phone:
Client phone
 
Current Living Situation:
Text field
 
If currently in a facility or inpatient treatment:
Whats the best way to cordinate admissions? 
 
Name:
Text field
Phone:
Client phone
Email:
Client email
 
 

Contacts

Emergancy Contact:
Contact

Insurance

Insurance provider(s).
NOTE: This Information is REQUIRED, referrals will not be accepted if this information is not provided
Insurance
 

Medical History/Substance Abuse History

Medical History/Substance Abuse History:
Last date of use:
Date
Substance(s) of abuse in the last 12 months: Add multiple by clicking in the box and selecting different options
Client substances of choice
Clinical diagnosis: Add multiple by clicking in the box and selecting different options
Client diagnosis
Health problems: Add multiple by clicking in the box and selecting different options
Client health problems
Allergies: No allergies? Move on to the next question.
Client allergies
 

Has any of the following test been done in the past 12 months?

Medical Tests

Criminal History

If you answer yes please provide details:

Sex charges:

 Radio buttons Text field

Arson charges:

 Radio buttons Text field

Assault charges:

 Radio buttons Text field

Probation or Parole:

 Radio buttons Text field

Pending charges:

 Radio buttons Text field

Treatment Program

Enorllment in an IOP (Intensive Out Patient) Program IS REQUIRED:
Text field
 

Client Referral Source

Text field

Date:

Anticipated admit Date:
Client admit date
 
 Is there any other information that may be helpful to All In Recovery? 
Text field

Comprehensive Assesment 

Referrals are accepted from treatment centers, case managers, discharge planners, and other providers.
After completing this referral form, please send clients Comprehensive Assesment or Summary to:

Email: info@allinrecovery.care

or

Fax: +1 651-677-2332

 

Thank You, We Will Be in Touch Soon! - All In Recovery

If you dont hear back from Admissions by the next buisness day Please give us a call at 651-478-0649