Pennsylvania Counseling Services

Opioid Use Disorder Center of Excellence Referral Form


C.O.E. County *
Name of Person Referring *
Relationship To The Client *
Referral Agency *
Referral Phone Number *
Client Gender *

          

Client Name *
Client Date of Birth *
Is the client in a residential facility/program? *

          

If YES, where? *
Client Address *
Client Primary Phone Number *

          

Client Secondary Phone Number

          

What is the best way to contact the client? *
Does the client have an Opiate Use Disorder? *

          

* To qualify for Care Navigation and Peer Support, they must have current or past opiate use *

Reason For Referral *
Are you referring the client for (check all that apply) *