Referrals

Referral for Mental Health and Substance Use Disorder Services

Welcome! Thank you for considering CenClear for your Mental Health or Substance Use Disorder treatment needs.

This form will be used to refer you, or the person you are referring, for needed services. If you have any questions or need assistance completing this form please call us at 1-877-341-5845.
No information about you or the person you are referring will be released without written consent. All of our services are confidential.
CenClear does not discriminate on any basis including a person's age, sex, color, race, disability, religious creed, lifestyle or source of payment.

Referral Source Phone Number/Email Address*:
Date of Referral:
Name of Referred Individual:
Medical Assistance Number if Applicable:
Please Provide Your Insurance Information (If you do not have insurance, please type "None" in the Insurance name box.
Insurance Company Name:
Policy Holder's Name:
Policy Number:
Group Number:
Please complete the following information:
Age:
Identified Gender:
Date of Birth:
Social Security Number:
Please enter the demographic information
Street Address:
City:
State:
ZIP Code:
County:
Phone (Home):
Phone (Cell):
Legal Guardian Name (if applicable):
Marital Status:
Family Doctor:
Referral Source (Name/Agency):
Is the Applicant currently receiving services?:
If the applicant is receiving services, please list the Agency name and Service:
Agency:
Service:
Please list areas of concern ::
School Information
School Name:
Grade:
Do you have an IEP:
Vocational/Education (check all that applies):
Previous Diagnosis:
Requested Services (Mark all that are applicable with CTRL + Click)*Requires enrollment in another service. Cannot be delivered as a standalone.:
Thank you for completing the Referral form for Mental Health and Drug and Alcohol Services. Once your form is submitted it will be reviewed. A CenClear staff member will then contact you to discuss services you or the person being referred may qualify to receive. If you have a document you would like to send as an attachment please email it to mhreferral@cenclear.org In the subject line of the email please write: (Patient's Name) Referral Attachment. If you have any questions or concerns or need help completing this form please contact us at 1-877-341-5845 ext. 2391.