Residential Rehab Referral

Residential Referral Portal Form

Yes

In order to progress with this form you must either log in or complete a simple registration for a new account. You can then continue to complete this form. This will enable you to track the form at a later date.

Current medication

Substance usage

Risks/hazards (eg, aggression, HIV, Hep?

Current offer of support.

Discharge arrangements.

Services involved. (include names) support from CGL and family

Something about why inpatient detox or rehab required? To discuss further

Financial contribution then relapsed explained.

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Residential Rehab Referral

Residential Referral Portal Form

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