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):