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FORA HEALTH WITHDRAWAL MANAGEMENT REFERRAL FORM(Please note that completion of the referral does not guarantee admission) Please fax completed form to: (503) 2001331 Attn: Megan Kim; then call and
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How to fill out detox referral form
How to fill out detox referral form
01
Obtain a detox referral form from a healthcare provider or treatment facility.
02
Fill out all required personal information, including name, date of birth, address, and contact information.
03
Provide detailed information on substance use history, including types of substances used, frequency of use, and any previous detox experiences.
04
Indicate any current medical conditions or medications being taken.
05
Sign and date the form, acknowledging that all information provided is accurate and complete.
Who needs detox referral form?
01
Individuals who are seeking detoxification services for substance abuse or dependence.
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What is detox referral form?
Detox referral form is a document used to refer individuals to a detoxification program for substance abuse treatment.
Who is required to file detox referral form?
Healthcare providers, social workers, or individuals responsible for the care of someone struggling with substance abuse may be required to file a detox referral form.
How to fill out detox referral form?
To fill out a detox referral form, you will need to provide information such as the individual's personal details, medical history, substance abuse history, and reason for the referral.
What is the purpose of detox referral form?
The purpose of detox referral form is to ensure that individuals in need of substance abuse treatment are connected with appropriate detoxification services.
What information must be reported on detox referral form?
Information such as the individual's name, contact information, insurance details, medical history, substance abuse history, and reason for referral must be reported on detox referral form.
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