Life Recovery Center Referral Form

Referral Form

Phone: 317.887.3290 | Fax: 317.672.6312 | LifeRecoveryCenter.net
Date

MonthDayYear
Date
Referred by
Agency
Referral Phone
Referral Email
example@example.com
Client Name
Client DOB
Address
Client Phone Number(s)
Client Email
example@example.com
Reason for seeking treatment/type of treatment needed
Client finances

Self-PayRecovery WorksMedicaidPrivate InsuranceOther
Referral for the following programs/services:

Substance Use Disorder Assessment/TreatmentBatterers Intervention Program (BIP)Anger ManagementPrime For Life® Education ClassesMental Health AssessmentIndividual TherapyPeer Support ServicesProblem Gambling TreatmentOther
Format

In-OfficeTelehealthNo Preference
Please upload any additional documentation you would like to attach to this referral

Please upload any referral paperwork
Cancelof
Thank you for the opportunity to work with your clients!
Life Recovery Center | 6350 N. Shadeland Ave #5, Indianapolis, IN 46220
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