Service Referral Form

You can also reach our Centralized Intake Team at
1-800-211-0996

Referral Date

Referral SourceHealthcare ProviderSocial Services ProviderOther

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 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

Additional Information

Please provide any additional information you think may be needed/helpful.

Consent

Is the participant aware they are being referred to StartCare for substance use disorder and/or mental health care?YesNo

Has the participant reviewed and completed a consent form regarding communication between the referring party and StartCare?YesNoPLEASE NOTE: A consent is not required to make a referral. However, it will allow StartCare 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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