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Alcohol & Drug Treatment Referral Form Mobile App

The Alcohol & Drug Treatment Form mobile app is an easy to use referral form for patients being referred to your treatment center for programs related to substance abuse, drug addiction, drug rehab, and other addiction related problems. Basic information is included for patient/client address, or guardian details if the patient or client is a minor, as well as the type of billing. Referral service information is also gathered, including a reason for referral.

The form also allows for electronic signature and date by both the referrer and patient or guardian, and can include information and details of addresses for different treatment centers.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Alcohol & Drug Treatment Referral Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Patient Name

  • Ico date

    Date of Birth

  • Ico textbox

    Parent(s)/Guardian Name(s), if a minor

  • Ico statictext

  • Ico statictext

    Home Address

  • Ico textbox

    Street

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico textbox

    Zip Code

  • Ico textbox

    Phone Number

  • Ico dropdown

    Is it ok to leave a message at this number?

  • Ico dropdown

    Payment Method

  • Ico textbox

    First and Last Name

  • Ico date

    Date of Birth

  • Ico textbox

    Organization

  • Ico textbox

    Street

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico textbox

    Zip Code

  • Ico textbox

    Phone Number

  • Ico textbox

    Fax Number

  • Ico multiline

    Reason For Referral

  • Ico statictext

    - All programs start with a comprehensive assessment to determine appropriate level of care.

  • Ico statictext

    [Insert Addresses of Treatment Center/s}

  • Ico signature

    Referral Signature

  • Ico date

    Date

  • Ico statictext

  • Ico signature

    Patient Signature

  • ...and More!

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