Road to Recovery, Inc.  All rights reserved; 1995-2015
Referral e-Form
Road to Recovery provides outpatient behavioral health services for individuals with
co-occurring mental health and substance abuse disorders. Finding the most appropriate
mental health counseling or substance abuse treatment center for an individual's specific
needs can be a daunting task and we are here to help you along the way.

In addition to our services, we also provide professional consulting and referral services
for in-patient treatment, self-help and support groups for specific substance related
programs and dual diagnosis when in-patient treatment is the best course of action.

Our purpose is to improve the access to proper substance abuse and mental health
services, to educate families and the general public about dual diagnosis, alcohol and drug
addiction, and help those who suffer from substance abuse and co-occurring disorders find
the best possible resources for their specific needs.

We know how confusing the search for the best and most affordable treatment services
can be, and the importance you place on
affordability, accessibility and also on
linguistically and culturally competent services.

For assistance in finding the best Road to Recovery location and most convenient hours of
operation to serve your needs, complete our confidential online referral form or call Toll
Free 1-866-950-5601 and we will help you find the facility that meets your needs and
budget.

If you wish to make a referral from a social services agency (DFCS, DCS) or if you are a
member of the Court system (Courts, Probation, Parole) in the United States; please
identify yourself as such and complete the online referral form and one of our staff
members will assist you in no time.
"A journey of a thousand miles starts with the first step"  
Please Fill Out All Applicable Fields On This Form
* Required Field
*
Referring Agency:
*
Referral Source Name:
Title:
*
Telephone:
*
e-mail:
*
Party responsible for all
incurred fees
*
Name of person being referred
*
Gender
Male
Female
*
*
Date of birth (mm/dd/yyyy)
Street Address
*
City, State, Zip Code
*
Telephone
*
e-mail
Schedule one or more of the following services
First DUI Offender Evaluation
Multiple DUI Offender Evaluation
Risk Reduction Program (DUI School)
Substance Abuse Evaluations  (Non-DUI)
Alcohol / Drug Random Screening
Immigration Clinical Evaluation
Individual / Family Counseling
Defensive Driving Classes
Mental Health Evaluation
Family Violence Intervention Program
Parenting Skills Program
Anger Management Program
One-Day Shoplifting Awareness Program
Values Clarification Program
Alive @ 25 Program
Victim Impact Panel
Theft Awareness Program
*
Please provide detailed reasons for this referral:
We would like to Thank You in advance for your referral. You can
download our Referral Form by clicking on the referral form button or
complete our convenient electronic referral form below and we will
contact you as soon as possible.
770-220-2885
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