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

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

Substance Use History

Drug of Choice

Last Date of Use (Primary)

Leave Blank if Unknown

Secondary

Secondary Route of Administration

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

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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Send me a copy of my responses

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