Reboot Retreat Referral Form
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1
2Referral Form for the Reboot Health and Wellness Retreat
Service Member Information
Name:
Date of Birth:
Gender:
Male
Female
Services Requested:
Health & Wellness Retreat Referral
Limited Use Policy Referral
CONTACT NUMBERS:
Text Message ok?
Yes
No
EMAIL ADDRESS:
Unit Information: *Unit will not be contacted
Unit:
Address:
Readiness NCO-Contact Information (phone/email):
Insurance Information:
*Services for the retreat are of no cost to the SM –data on insurance are for post retreat planning
purposes only
Type of Insurance
Medicaid (county)
Healthchoice
BCBS
Other
If no insurance-N/A-
Referral Source Information:
Complete this section so we can contact you after the referral is made.
Name
Mailing Address
Phone#
Email address
How did you hear about the Health and Wellness Retreat?
Health Information:
Current medication & dosage
Current Diagnosis if any?
Are you currently detoxing?
Prescribing Physician name & Phone
Current Mental Health Symptoms:
Unknown
Not Present
Mild
Moderate
Severe
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Parent category: Medical