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About Us
Our Team
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Programs & Services
Housing
Get Involved
News & Events
Submit a Housing
Referral
Please fill out the form below
Date of Referral:
MM slash DD slash YYYY
Referral Source Information
Referring Agency / Person:
Contact Name & Title:
Phone
Email
Fax (if applicable):
Participant Information
Full Name:
First
Last
Date of Birth:
MM slash DD slash YYYY
Phone
Email
Emergency Contact & Phone:
Current Address / Facility:
Clinical & Recovery Information
Primary Substance Use History:
Date of Last Use:
MM slash DD slash YYYY
Currently in Treatment?
Yes
No
If yes, where?
Level of Care:
Detox
Residential
IOP
OP
MAT
Other
Current Recovery Support Provider / Case Manager:
Phone
Email
Is participant currently prescribed MAT?
Yes
No
If yes, medication(s):
Behavioral Health Diagnosis (if known):
Not disclosed
(if known):
Legal Considerations
Legal Status:
None
Probation
Parole
Drug Court
Other
Officer Name (if applicable):
Phone
Email
Any court-ordered housing or treatment?
Yes
No
If yes, explain:
Medical Information
Any medical needs or physical limitations?
Yes
No
If yes, explain:
Current Medications List Attached?
Yes
No
(Participant must bring medications in original bottles)
Safety & Housing Needs
History of violence or safety concerns?
Yes
No
If yes, explain:
Smokes or vapes?
Yes
No
Needs handicap-accessible housing?
Yes
No
Preferred Move-In Date:
Transportation assistance needed?
Yes
No
Supporting Documents (if available)
Assessment
Discharge summary
Medication list
Release of Information
ID / Insurance copy
Referral Reason / Notes:
ROIs
Yes
No
Refferral source confirms signed ROI for communication with Samaritan House: (participant will sign at intake)
Signatures
Referring Party Signature
First
Last
Date
MM slash DD slash YYYY
Consent
I consent this as my electronic signature.
Participant Signature
First
Last
(if present)
Date
MM slash DD slash YYYY
Consent
I consent this as my electronic signature.
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