Michigan Department of Corrections

Substance Use Referrals

Note: Fields marked with an asterisk * are required.

NOTE:

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

Demographic Information

Legal Status*

Select or enter value

Individual Name*

Offender Number (Number Only)

Individual Address*

City*

State*

Zip Code*

Phone Number

Phone

Full Social Security Number

Date of Birth

Is the individual a veteran? *

Yes

Not Certain

Does the individual have a legal gurardian? *

Yes

Individual's Current Location: *

Community

County-Jail

Prison

Other

Other, Please Describe

Substance Use History

Drug of Choice*

Select or enter value

If Other was selected, please explain

Last Date of Use (Primary)

Leave Blank if Unknown

Secondary*

Select or enter value

Secondary Route of Administration

Select or enter value

Last Date of Secondary Use

Leave Blank if unknown

Have you had a recent drug screen? *

Yes

Background Information

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

Yes

Previous Treatment:

None

Both Outpatient and Residential

Outpatient

Residential

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

Yes

Recent Arrest by criminal justice agency for use?

Yes

Other

Current or Recently Released Individuals:

Yes

Conviction History

Arson

Yes

Sex Offense

Yes

OUIL3

Yes

Other Prior Conviction(s)

Medical HIstory

Current Medical Conditions:

Pregnancy*

Walks without assistance

Other

Other Medical History

Current or Previous Mental Health Issues

Yes

Currently Taking Medication:

Yes

Availability

Immediate Availability*

Yes

Contact Information

Referred by Name:*

Name of Agency *

Agent Phone Number *

Agent's Email Address:*

Supervisor's Email Address: *

Additional Comments:

Use the below space to attach supporting documentation*

The following documents should be uploaded here:

NOTE: BOTH FORMS ARE REQUIRED.

FAILURE TO SUBMIT BOTH FORMS WILL RESULT IN FORM BEING DENIED.

Form CFJ-306 MDOC Referral Form

Form 5515 Consent to Share Information

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