Psychologist

Referral Form

Instructions

Substance Use Disorder classes are designed for those who may have an issues with using drugs.

Please fill in all the form fields as accurately as possible. If there is missing or incomplete information, it may cause a delay in processing your referral information.

You have two options to submit a referral to us.
> It can be printed, completed and faxed to 866-798- 2727. ATTN: Mrs. Shanks.
70 x 7 Mental Health 70 x 7 DWI 70 x 7 SUD Referral Form

> Fill in the form to the right and submit it through our secure website.

For questions about completing this form or inquiries about our services please call 410-624- 5037 or email info@70x7wm.com and a program representative will reply within 1 business day.

Substance Use Disorder Referral Form

Client Information

Please Select Referral Type
Please Enter Name
Please Enter Phone No.
Address Line 1 Please Enter Current Address Address Line 2
City
State
Zip Code
Please Enter Birth Date
Please Enter Social Security Number
yes
no

Referral Source Information:

(Please write name of person who needs progress reports, incident reports,etc.)
Please Enter Referring workers Contact Number
Please Enter Referral Email Please Enter Valid Email

Client Treatment Information

(ex. 1x/wk., 3-5x/wk. 1x/mo. etc.)
(ex.$10.00 worth, 2 12oz. beers etc.)
yes
no
yes
no
(ex. Difficulty hearing, speaking, talking, walking etc.)

Recommended Services

Substance Abuse Evaluation- Consists of one 2hr. session.
Outpatient Treatment - 12-18 week program (6-8 hours per week) for adults. Random Drug Testing, individual, group, and self-help meeting attendance is required.
Intensive Outpatient – 12-24 week intensive program (9-12 hours per week) for adults. Individual, group, and self-help meeting attendance is required. Random Drug Testing required.

Signature

Please Type your full name as your digital signature. Complete the captcha and click the 'Submit' button
Please Enter Signature
Please Enter Date