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AdaPt 2 HeaLing LLC, Provider Referral Form
Adapt 2 Healing LLC, Service Registration Form ... Update 2020
* Indicates required question
Email
*
Your email
Please, Once Registration is complete Please provide a Valid Picture ID will be required with registration. Thank You for helping me properly Identify the persons receiving services. Are You able to Provide a State Photo ID, A accredit Student ID with updated information?
*
yes
No, If No and you would like support in how to receive proper Identification. complete form check Consultation Box
DATE:
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MM
/
DD
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YYYY
Name of Agency referring services, Address
Your answer
You are registering for non- clinical community Peer Based Recovery Support Services with Adapt 2 Healing LLC. For Mental Health Healing and Wellness and /or Family Assistance and Support. These services are Fee -for- service and self- pay. Type of organization:
Community Service Board
School System
Department of Justice including Juvenile
Department of Social Services
Other:
Phone Number
Your answer
Contact Person/ Case worker for this referral and Participant(s) .
Your answer
Phone Number
Your answer
Email
Your answer
Has this agency or contact discuss this referral to the family? If Yes, We will follow up with the family. If No, would you like support talking with the family about the services?
Your answer
Has this agency or contact used this type of support service previously
Yes
No
Clear selection
If YES, Please state which services, organization and year. IF NO, Please indicate if you would like a additional information Thank You for supporting community support services Adapt 2 Healing LLC
Your answer
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