Road to Recovery, Inc.  All rights reserved; 1995-2011
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.
Your call is
important to us
After Hours
770-990-3271
Toll Free
1-866-950-5601