Referral Form - Foothills Recovery

Make a Referral

365 Foothills Academy Road
Albany, KY 42602

Phone: 606-388-4607
Fax: 606-387-4509
Email: ssimmons@cbiky.org

Thank you for taking the time to refer someone to Foothills Recovery. Your willingness to reach out could be the first step toward changing someone’s life. Please complete the form below, and our team will follow up promptly to coordinate next steps.

Download the referral form or use the digital form below to submit your referral.

Referral Source Information

Client Name

First

Last

Client Age

Client Date of Birth

Example: "07/07/1982"

Client Social Security Number

Client Phone

Client Email

Client Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance

Yes
No
Unknown

Name of Insurance Carrier (If Known)

Client Information

Referred by

Date

Title/Agency

Phone

History Medications Name

Reason(s) for Referral/Client Needs

Substances Used/Date of Last Use

Legal Issues/Charges/Court Dates

History of Violence

Yes
No
Unknown

If 'yes', please provide details

Previous Treatment

Medications

To Be Completed by Foothills Recovery

Staff Receiving Referral:

Date Staff Responded to Referral:

Comments/Action Taken:

Date Intake Scheduled:

Therapist:

Make a Referral

Referral Source Information

Client Information

To Be Completed by Foothills Recovery

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