Durham LRC Referral Form

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Please correct the fields below:

Please enter the following information to complete a referral for the Durham LRC

1

Client Profile

 *
Client Profile
2

Address

 *
Address

General Information

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Referral Date
 *
4

Referral Source

 *
Referral Source
5
Referral Contact Information
Referral Contact Information
6

Is the client currently in custody?

 *
Is the client currently in custody?
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If you answer Yes to the above question, please let us know your current location:
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Is the client currently receiving services from Substance Use Disorders or Mental Health provider?
Is the client currently receiving services from Substance Use Disorders or Mental Health provider?
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Reason for referral
 *
  1. To receive a copy of your submission, please fill out your email address below and submit.