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  • Referral Guidelines

    1. To refer a potential client, please complete and submit this form, and upload a copy of the following on the Documentation page:

    • Comprehensive Clinical Assessment
    • ASAM Criteria Form
    • Release of Information
    • Applicable lab work
    • Progress notes, and/or
    • Discharge instructions
    • Prescription List

    *PLEASE UPLOAD DOCUMENTATION AS ONE SINGLE PDF IF POSSIBLE*

    2. All of the submitted information will be reviewed by the clinical team and you will be notified within 3 business days of any additional information that is needed and/or acceptance of referral.

    3. If the referred client is accepted into the inpatient program, they are strongly encouraged to arrive with a 30-day supply of all prescribed medications. If a 30-day supply is not available, the client must bring their current medications along with an active prescription that can be filled upon arrival. This ensures a smooth transition into treatment and uninterrupted care.

     

    This is the fastest way to reach us. You will receive a follow-up within 3 business days (72 business hours). 

     

    Please complete the following Referral Source section, then proceed by clicking the "Next" button below.

  • Referral Source


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  • Documentation

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    REQUIRED DOCUMENTS PREFERRED DOCUMENTS
    • Comprehensive Clinical Assessment
    • Medical History/Record
    • Release of Information Form
    • Applicable lab work
    • Medication List 
    • Progress Notes
    • Medication Administration Record (if applicable)
    • Discharge Summary and/or Instructions
    • Legal Guardian Consent Form (if applicable)
    • TB skin test results from the past 30 days

     

    • Please note: This documentation portal and referral form are encrypted in compliance with HIPAA regulations to ensure client security and confidentiality. If the required documentation is incomplete or does not provide sufficient information for a comprehensive assessment, we will schedule a phone interview with the client prior to program acceptance to ensure a smooth transition and avoid any delays upon arrival.
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  • Client Information

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  • * IMPORTANT LEGAL GUARDIANSHIP INFORMATION *

    If the client has a legal guardian, there must be documentation attached to this referral. In addition to this consent form, the legal guardian must be present throughout the intake process (admission, assessment, person centered plan if applicable, etc.), and present for the discharge process.

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  • Accessibility:

  • *** PLEASE NOTE: If you answered yes to this question, please be advised that while handicapped accessible rooms are available, all clients must be able to complete ADL’s independently.***

  • Attestation

  • By checking the box below, I, {clinicianName} , confirm that this referral form has been completed accurately to the best of my knowledge on behalf of a credentialed healthcare provider. I am referring the individual named in this form to Anuvia Prevention and Recovery Center for assessment and potential substance use disorder treatment.

    I acknowledge that:

    1. I have obtained the necessary consent from the referred individual to share their information with Anuvia Prevention and Recovery Center.
    2. I understand that the information provided will be used by Anuvia to determine appropriate services and care for the referred individual.
    3. I have explained to the referred individual the purpose of this referral and the type of services that may be provided by Anuvia.


    I attest that the information included in this referral is accurate and based on my professional assessment and/or the client’s medical record. I also understand that Anuvia will handle this information in accordance with HIPAA and other applicable privacy laws.

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