Make a Referral

Referral Form

Name of Person Being Referred:

Patient's Date of Birth:

Patient's Phone Number:

Reason for Referral:

Summary of Facts/Observations/Supporting Documentation

Drug Test: Reported/suspected drugs of use/abuse (check all that apply):

Patient's reported date of last use:

Patient's last drug test was (date):

Results:

If positive, which substance(s)

Referral Agency:

Referral Agency Contact Person:

Referral Agency Phone Number:

Referral Agency Email Address:

130 Hudson St
Chester, SC 29706-1524

Phone: (803) 377-8111
Fax: (803) 581-5380

Monday & Wednesday
8:00 a.m. - 5:00 p.m.

Tuesday & Thursday
8:00 a.m. - 7:00 p.m.

Friday
8:30 a.m. - 12:00 p.m.