Alcohol & Drug Treatment Referral Form

Form Template

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.

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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.

  • Signature Capture
  • Submission Editing
  • Reference Data
  • Dispatch
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  • iPhone
  • iPad
  • Android
  • Windows
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  • Quickbooks
  • Salesforce
  • Google Docs
  • Dropbox
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Don't take our word for it...

“I’m not a tech guy and I was able to pick this thing up in probably an hour, and actually start to build apps. I’ve done them over lunch when I’ve gotten frustrated with a process that didn’t exist in our company. So for non tech people who’ve got a problem, the support here is awesome and I’d recommend it to anybody, not just in our industry.”

Dave Kramer, PennLine Service

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