Community Partner Referral Form

Referral Date

Organization Name

If this is an NYP referral: Please select the referring campus

Case Manager/Contact Name

Email Address

Contact Phone Number

Reason for Referral (check all that apply)Opioid Use DisorderAlcohol Use DisorderAdolescent TherapyAdult Mental Health/Co-occurring SUDOther 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:YesNo

Street Address

City

State/Province

ZIP / Postal Code

Country

Primary Phone

Alternative Phone

Participant Demographics and Language

Sex at Birth

Gender Identification

Race

Ever Served in Military?YesNo

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?YesNo

Has the participant reviewed and completed a consent form regarding communication between the referring agency and StartCare?YesNoPLEASE 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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