Printer Friendly Call Log

  1. What is your name? How can we reach you? - (Person on Phone - POP)
  2. Where did you hear about us?
  3. Where are you calling from?
  4. Is this for you or another person in question? (PIQ)
  5. What is the name of the person in question (PIQ)? (If #4 is NOT "SELF")
  6. What is the primary issue? (Choose 1 or more)
  7. What Type of help are you looking for? (Choose 1 or more)
  8. Are you willing to go out of state?
  9. Are there finances available?
  10. Is there insurance?
  11. Notes
  12. Manual Referral Notes: Please include notes for referral on reverse side.
    1. Choose from: Detox, Interventionist, InPatient, OutPatient, Sober Living, Doctor, Therapist, CAST, Other, Unknown

    2. Include name of referral

    3. Include any referral notes

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