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Service Referral Form
You can also reach our Centralized Intake Team at
1-800-211-0996
Referral Date
Referral Source
Healthcare Provider
Social Services Provider
Other
Organization Name (as applicable)
Organization Description (as applicable, e.g., ACT, shelter, FQHC):
Case Manager/Contact Name
Email Address
Contact Phone Number
Reason for Referral (check all that apply)
Opioid Use Disorder
Alcohol Use Disorder
Adolescent Therapy
Adult Mental Health/Co-occurring SUD
Other Substance Use Disorder
Participant Basic Information and Contact
First Name
Middle Name
Last Name
Date of Birth
Primary Insurance Name
Insurance ID Number
Email Address
Currently Experiencing Homelessness:
Yes
No
Street Address
City
State/Province
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Australia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cabo Verde
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Guernsey
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
Saint Helena
Saint Pierre & Miquelon
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
US Minor Outlying Islands
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Primary Phone
Alternative Phone
Participant Demographics and Language
Sex at Birth
Male
Female
Select
Gender Identification
Male
Female
Non-Binary
Other
Select
Race
Race
American Indian or Alaskan Native
Asian/Pacific Islander
Black/African American
Hispanic
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White/Caucasian
Don't know/not sure
Not disclosed
Additional Information
Please provide any additional information you think may be needed/helpful.
Consent
Is the participant aware they are being referred to START Treatment & Recovery Centers for substance use disorder and/or mental health care?
Yes
No
Has the participant reviewed and completed a consent form regarding communication between the referring agency and StartCare?
Yes
No
PLEASE NOTE: A consent is not required to make a referral. However, it will allow START Treatment & Recovery to speak with the referring agency to coordinate care, within the limits established by the participant. You may download a consent form that meets our compliance standards by clicking the links at the bottom of the page.
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Download Consent Form – English
Download Consent Form – Spanish
About
Who We Are
Our Founder
Locations
Leadership
Our Community
Programs
Opioid Treatment Programs
REACH Intensive Outpatient Program
Teen START
Licensing & Accreditation
Research
Get Involved
Careers & Opportunities
Support Us
Contact Us
