Test – Generic Referral Form

Referral Type:

Name:
Case #:

Address/ City / Zip:

Offense:
BAC:

Date of Birth:
Phone Number:

Does the client have a no contact order/PPO against them?

If (YES) What is the name of the person they cannot be in contact with?
Is the client charged as a juvenile?

Is the client part of pretrial services?

If pretrial services (YES) What is the name of the pretrial agency?
Is the client currently on bond?

If bond (Yes) What are the bond conditions of bond? Bond amount type (personal, 10%, etc)?
Reporting Probation Start Date:
Reporting Probation End Date:
Probation Officer or Referrer Name:
Sentencing Date:
District/Circuit Referring Court:
Presiding Judge:
Client to contact MDADS by: (if no date is given there is a standard 48 hour required contact time)
Court Contact Person:
Your Phone:
Your Email:
Your Fax:
Which way do you preferred to be contacted?

DRUGS & ALCOHOL TESTING

Testing Requirements:

Do you want all tests performed by lab only? (no rapid testing allowed)

Testing Frequency:

Comments/Special Requests:

COUNSELING

ONE DAY CLASSES

ALCOHOL & DRUG COURSES***

***All groups come with drug testing, materials and speakers (included in cost)
AM/DV/ADA BEHAVIOR GROUPS & COURSES
wkswks

THERAPY SESSIONS

SCREENING/ASSESSMENTS/EVALUATIONS*

***All assessments are monitored
I, hereby authorize Michigan Diagnostic Alcohol & Drug Services, (MDADS) its director or designee, to release information to (person and/or referring agency) and to receive information from and/ or the referral party and when necessary, offer recommendations for additional referral services. The purpose of this disclosure is to assist the court and/or the referring agency inreaching a satisfactory disposition of my case. The authorization will remain in effect until the purpose for which it was given fore no longer exists. In the case of criminal justice referrals, the authorization will expire when the program receives official written notice of a change in my legal case status. I agree to the program rules and terms of MDADS and will sign a MDADS agreement to such rules and terms. I agree to contact and comply with the MDADS order that is listed above within 48 hours (or listed above by referring agent) of receiving this notice from the referral party. If I do not comply with all MDADS conditions, the court and/or referral party will be notified. Non payment to MDADS is consider being non-compliance and may violate my terms or agreement with the court and/or the referral party and may end up a violation of my probation. (if a legal/court case)
Signed by Client:
Signed by Referring Agent:
Date:
Date: