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Substance Abuse Referral Form

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  • Substance Abuse Referral Form

Substance Abuse Referral Form

Referral Information

Consumer Information:

If the consumer is a minor, copies of legal documents related to a minor’s status must be provided prior to services being rendered, i.e. (court orders, custody agreements, etc.)

Reason For Referral

Please include pertinent information, listing patient’s needs and all significant current symptoms
Please include the following information per substance: Type of Substance, Age of First Use, Route of Transmission, Frequency of Use, and Date of last Use
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  • (240) 455-6584
  • (301) 328-0651 Espaniol
  • (301) 576-7736
  • info@ctohs.com
  • 8121 Georgia Ave, Suite 201, Silver Spring MD 20910
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