Make A Referral

We Do Recover

Fill out the Confidential Referral Form Below.

    Your Name
    Your Email
    Your Phone
    Patient's Name
    Patient's Email
    Patient's Phone
    Date of Birth
    Drug of choice
    When did they last use it?
    If more than one drug when did they last use each drug?
    Are they on maintenance medication like Suboxone or methadone?
    If yes, what program do they go to for their medication?
    Do they have an ID?
    If yes which state is the ID?

    What insurance do they have?
    Please provide the Social Security Number to verify insurance.

    Please Select Office

    Service Requested