Referral Form

Client Info

Client Name *

Expected Hospital Discharge Date *

SSN *

DOB *

Age

Client Email

Client Phone

Insurance & Number *

Referred From *

Independent of ADLs? *

Yes

Behavioral / Legal Risk Factors? *

Registered Sex Offender

History of Sexual Offense (unregistered or pending)

Violent or Aggressive Behavior

On Parole or Probation

In active withdrawal/detox

Behavioral or Resource-Intensive Needs (may require closer supervision or support)

None of the above

Notes/Clarification

Behavioral History information is not disqualifying, it just allows us to better serve the individual in the program.

Medical Diagnosis & Special Needs

Contact Person

Name *

Phone *

Email *

Please send medications and medical supplies (including O2) for 2-3 days. Please forward progress notes, medical orders, H&P and discharge summary to Referrals@athrc.com. Incomplete submissions could cause delays in the acceptance process.

Captcha *

reCAPTCHA is required.