Referral Form | Nova Recovery Center

Nova Recovery Center Referral Form

Thank you for referring a client to Nova Recovery Center. Please complete the form below with as much detail as possible.

Disclaimer & Agreements: By submitting this referral, you confirm that you have appropriate authorization to share the client information provided. Nova Recovery Center will use this information solely for the purpose of coordinating care and will maintain confidentiality in accordance with applicable federal and state privacy laws (including 42 CFR Part 2 and HIPAA where applicable). Submission of this form does not guarantee admission; acceptance is subject to clinical assessment and program availability.

Person Completing Referral Form

Name

Email *

Phone Number *

Agency Making the Referral

Client Information

Name *

Date of Birth *

Phone Number *

Email Address (if applicable)

Individual Gender

Individual Primary Language

English Other

Type of Service Needed

ASAM 1.0 ASAM 2.0 Chemical Health Assessment Other

Emergency Contact

Full Name

Phone Number

Insurance Information

Does the individual have active insurance?

Yes No

Insurance Provider

PMI #

Member ID # (if applicable)

Consent for Information Release

Additional Notes