Get Naukeag Community Referral

Filling out the Naukeag Community Referral is an important step towards seeking assistance. This guide provides clear, step-by-step instructions to help you complete the referral form accurately and efficiently.

Follow the steps to successfully complete the Naukeag Community Referral.

1. Use the ‘Get Form’ button to access the Naukeag Community Referral and open it in a convenient format for editing.
2. Begin by entering the date of your application at the top of the form. Complete the patient information section including your name, age, gender, and date of birth.
3. Fill out your address, state or country, ZIP code, and contact details, including email and phone numbers. Indicate your preferred method of contact as well as the best time to reach you.
4. In the presenting problem section, check all boxes that apply to issues you are currently facing. Additionally, briefly explain why you are considering admission to the Naukeag program.
5. For current treatment details, indicate whether you have active treatment providers and provide details about any psychiatric diagnoses. List the names and contact information of your current treatment providers.
6. Complete the drug use history section by listing all primary and secondary substances you have used, including the age of first use and last use, as well as frequency of use.
7. Fill out the medical section by mentioning the date of your last physical check-up, your primary care physician's name and contact, and any current medical conditions.
8. Address risk factors related to mental health and safety by responding to the questions regarding history of suicide attempts and harm to others.
9. In the legal section, indicate if you have any current legal charges, probation status, or restraining orders.
10. Outline your aftercare plans by specifying your housing plans and treatment intentions following your time at Naukeag.
11. Provide your pharmacy information necessary for medication prescriptions, including cardholder ID and pharmacy contact details.
12. Finally, review all entries for accuracy. You may save changes, download, print, or share the completed form as needed.

Take the next step in your journey by completing the Naukeag Community Referral online today.