Adolescent Referral

This form will take approximately 10 minutes to complete, and is HIPAA compliant. By submitting this form, I certify that the adolescent and his/her legal guardian understand that they are being referred to Keystone for an assessment and possible treatment. Keystone conducts walk-in substance use assessments (no appointment needed) at our 199 South Herlong Avenue location during the following times: Monday-Friday, beginning at 8 AM. Please note: Please note: Substance use assessments are first come, first served. Keystone does its best to assess all patients who walk in, but there are days when we do not have capacity to see all patients. In those cases, patients are asked to return another day. Mental Health/Counseling assessments are conducted only with an appointment. See more about Microsoft Forms’ HIPAA Compliance here: https://bit.ly/3zTE28f When you submit this form, it will not automatically collect your details such as name and email address unless you provide the information yourself.

Referral Source(Required)

This could be DSS, DJJ. Probation, school, self, etc.) Please let us know who is making the referral.

Referral Date(Required)

Patient Name(Required)

Date of Birth(Required)

Gender(Required)

Parent/Guardian(Required)

Relationship to Patient(Required)

Email(Required)

Patient Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Country Phone Number

Reason for Referral(Required)

Please be as specific as possible.

Current school/last school attended(Required)

Current grade/last grade completed(Required)

Services requested

Check all that apply.

Mental Health/Counseling Assessment (may include urine drug screen) Provided by appointment only. We’ll contact you to schedule the appointment after this form is received.

Substance Use Assessment (includes urine drug screen)

Drug screen only (hair)

Drug Screen only (urine)

If referral is for substance use, standard drug screen panel will be utilized. Please specify below if there is a need for a specific test, and what substance needs tested.

If referral is for substance use, please indicate date of last use below

Is the patient a Medicaid recipient or covered by private insurance?(Required)

Yes

Referral Source Name(Required)

Referral Source Phone Number(Required)

Country Phone Number

Adolescent Referral

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