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Please Provide The Following Information For New Intake Referrals
(Counselling, Medication Management, Substance Use Disorders, Psychiatric and Mental Health Evaluations)
Patients Name (Last, First): *
Contact Person: *
Phone Number: *
Patients Date of Birth: *
Email (Optional)
Services Requested *
New Intake Assessment
Substance Use Assessment
Med Management
Crisis Management
Case Management
Drug Screen
EDD paperwork Initial
EDD Renewal
Off Work Note
Checkboxes *
New Refferal
Follow Up Care
Not Listed
Urgency *
--
Today - Before Midnight
24-48 Hrs
Within 72 Hrs
Addional Comments (Optional)
some-randome-random
www.Inlandempirementalhealth.com
Customerservice@Inlandempirementalhealth.com
Tel: 480-999-8295
