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ALCOHOL & DRUG FREE ENVIRONMENT

For Client Referal?

Please fill out the following form to help us get to know the client.

First Name

Email Address

Last Name

Date of Birth

Gender? *

Male

Female

Veteran? *

No

Yes

Reason for referral:

Medical Diagnosis

Psychiatric Diagnosis

Criminal Background? *

No

Yes

If yes for Criminal Background, explain: (Type "N/A" if answered No)

Activities of Daily Living Needs:

Income Source: *

SSI

SSDI

RSS

Private Pay

Other

Current Pharmacy:

Case Manager Name and Number

Mental Health Outpatient Services: *

Hamilton County Mental Health & Recovery Services Central Clinic

Greater Cincinnati Behavioral Central Community Health Board

Other

Negative COVID-19 test in the last 7 days? *

Yes

No

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Please allow 72 hours for a response. For emergency placement don’t hesitate to call the Admissions Director Ms. Scott BSN,RN at 513.276.8808

Courage House I: 513.245.0736
Courage House II: 513.245.0787

CourageHouse1LLC@gmail.com
CourageHouse2LLC@gmail.com

Mount Airy, Ohio

ALL RIGHTS RESERVED.

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