Treatment Referral Form

We are immensely grateful that you have made the courageous decision to embark on a new start in your recovery journey. Choosing to seek help and support is a remarkable step, and we are honored that you have placed your trust in us. We are fully committed to providing the assistance, guidance, and resources you need to achieve your goals, and we will be with you every step of the way!

Demographic information is collected and used responsibly, without treating individuals differently based on their demographics. The information collected is aggregated and anonymized to protect privacy.

Name *

First

Last

Middle Name *

Date of Birth *

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Phone *

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Race *

• American Indian
• Asian
• Black or African American
• Native Hawaiian
• White
• Prefer not to say

How did you hear about The Lotus Center, Inc.? *

• Agency Referral
• Word of Mouth
• Social Media
• Flyer
• Other

If you referred by an agency, who referred you? *

If you were not referred by another agency, use N/A

Email *

Gender *

• Woman
• Man
• Non-Binary
• Prefer not to say

Preferred Pronouns

Do you have Health Insurance coverage? *

• Yes
• No
• Would like assistance applying for health insurance.

If you do not have insurance, out of pocket cost is $160.00 for an assessment.

What insurance do you have? *

Please list NA if you do not have insurance.

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Referral Name/Agency *

Agency that referred you to The Lotus Center, Inc.

Referral Name/Agency Contact Information *

Provide email or phone number for agency that referred you.

Scheduling Preferences

If there are certain times that work best with your schedule include them here.

Do you want treatment services or just an assessment? *

• Treatment Services (Outpatient)
• Chemical Dependency Assessment
• Both
• Unsure

File Upload

Click or drag a file to this area to upload.

If you are an agency that has past assessments, any updates, etc. please include them here.

Submit