Michigan Department of Corrections
Substance Use Referrals

Crisis services are available 24 / 7 - 365:

Common Ground at 800-231-1127 and New Oakland at 877-800-1650

Reason for Referral

Request for Access Screening

Note: A "Request for Access Screening" includes medically necessary services, such as Detox / Residential and Medication Assisted Services (MAT)

Individual's Demographic Information

Individual's Demographic Information

Individual's Name

Offender Number (please use numbers only)

Address

City

State

Zip Code

Phone#

Phone

Social Security Number (full)

Date of Birth

mm/dd/yyyy

Is the individual a veteran?

Yes

No

Does the individual have a legal guardian?

Yes

No

Individual's Current Location

Community

Prison

County Jail

Other

Substance Use History

Substance Use History

Primary

Last date of use (primary)

mm/dd/yyyy

If date is unknown, check below.

Secondary

Last date of use (secondary)

mm/dd/yyyy

If secondary date of use is unknown check below.

Have you had a recent drug screen?

Yes

No

Other Information

Other Information

Recent arrest by criminal justice agency for use / possession of alcohol or controlled substance

Yes

No

Other

Previous Treatment

None

Outpatient

Residential

Outpatient and residential

For individuals currently in prison or with a recent release from prison:

For individuals currently in prison or with a recent release from prison:

Did the individual participate in Residential Substance Abuse Treatment For State Prisoners (RSAT) Program?

Yes

No

History of Conviction

History of Conviction

Arson

Yes

No

Sex Offense

Yes

No

OUIL 3rd

Yes

No

Current Medical Conditions

Current Medical Conditions

Pregnancy

Yes

No

Walks without assistance

Yes

No

Current or previous mental health issues

Yes

No

On Medication

Yes

No

Availability

Availability

Immediately available

Yes

No

Agent's Contact Information

Agent's Contact Information

Referred by Name

Name of Agency

Phone #

Phone

Agent's Email Address

Supervisor's Email Address

Additional Comments

Please provide any additional information not covered above.

Please attach the Consent to Share Behavioral Information

Please attach the Consent to Share Behavioral Information

Consent to Share Behavioral Health Information

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