Republic of the Philippines

Bangsamoro Autonomous Region in Muslim Mindanao

Province of Maguindnao
Municipality of Sultan Kudarat Maguindanao Del Norte
Municipal Anti-Drug Abuse Council
Community-Based Drug Rehabilitation Program

Referral Form
Outpatient/Recovery Clinic or Residential DATRCs
Referring Personnel:
Name: ________________________________________________________
Position: ________________________________________________________
Contact No: _____________________ Email: _____________________________

Referral Recipient Information:

Name: ________________________________________________________
Position: ________________________________________________________
Agency: ________________________________________________________

Referral Details:
Reason for Referral: ___________________________________________________
___________________________________________________
Date of Referral:___________________________________________________

Client/Patient Information (if applicable):

Name of Client/Patient: __________________________________________
Date of Birth: ________________________ Gender: ___________________
Address: ______________________________________________________
Contact No: _________________________

Referral Notes/Comments: _____________________________________________________

____________________________________________________________________________
____________________________________________________________________________

Attachments: ________________________________________________________________

I, _____________________________________ , hereby certify that I have obtained the

necessary consent from the client/patient below above to make this referral. I understand that
this referral may involve the sharing of sensitive information related to the client/patient's
condition and needs.

Client/Patient Name: ___________________________________________________________

I also understand that the information provided in this referral form will be used for the purpose
of assisting the client/patient with their specific needs and will be treated with the utmost
confidentiality in accordance with applicable privacy laws and regulations.

I hereby authorize the release of the information contained in this referral form to the recipient
and any relevant parties involved in the referral process.

[ ] I confirm that the client/patient has provided their consent for this referral.
[ ] I am the legal guardian of the client/patient and provide consent on their behalf.
[ ] I confirm that the client/patient has refused or is unable to provide consent, and I understand
the limitations this may place on the referral process.

_____________________________________ ___________________Signature
over Printed Name Date
 Republic of the Philippines
Bangsamoro Autonomous Region in Muslim Mindanao
Province of Maguindnao
Municipality of Sultan Kudarat Maguindanao Del Norte
Municipal Anti-Drug Abuse Council
Community-Based Drug Rehabilitation Program

Referral Form
Psycho-Socio-Spiritual Services
Referring Personnel:
Name: ________________________________________________________
Position: ________________________________________________________
Contact No: _____________________ Email: _____________________________

Referral Recipient Information:

Name: ________________________________________________________
Position: ________________________________________________________
Agency: ________________________________________________________

Referral Details:
Reason for Referral: ___________________________________________________
___________________________________________________
Date of Referral:___________________________________________________

Client/Patient Information (if applicable):

Name of Client/Patient: __________________________________________
Date of Birth: ________________________ Gender: ___________________
Address: ______________________________________________________
Contact No: _________________________

Referral Notes/Comments: _____________________________________________________

____________________________________________________________________________
____________________________________________________________________________

Attachments: ________________________________________________________________

I, _____________________________________ , hereby certify that I have obtained the

necessary consent from the client/patient below above to make this referral. I understand that
this referral may involve the sharing of sensitive information related to the client/patient's
condition and needs.

Client/Patient Name: ___________________________________________________________

I also understand that the information provided in this referral form will be used for the purpose
of assisting the client/patient with their specific needs and will be treated with the utmost
confidentiality in accordance with applicable privacy laws and regulations.

I hereby authorize the release of the information contained in this referral form to the recipient
and any relevant parties involved in the referral process.

[ ] I confirm that the client/patient has provided their consent for this referral.
[ ] I am the legal guardian of the client/patient and provide consent on their behalf.
[ ] I confirm that the client/patient has refused or is unable to provide consent, and I understand
the limitations this may place on the referral process.

_____________________________________ ___________________
Signature over Printed Name Date
 Republic of the Philippines
Bangsamoro Autonomous Region in Muslim Mindanao
Province of Maguindnao
Municipality of Sultan Kudarat Maguindanao Del Norte
Municipal Anti-Drug Abuse Council
Community-Based Drug Rehabilitation Program

Referral Form
Psychiatric and Medical Comorbidities
Referring Personnel:
Name: ________________________________________________________
Position: ________________________________________________________
Contact No: _____________________ Email: _____________________________

Referral Recipient Information:

Name: ________________________________________________________
Position: ________________________________________________________
Agency: ________________________________________________________

Referral Details:
Reason for Referral: ___________________________________________________
___________________________________________________
Date of Referral:___________________________________________________

Client/Patient Information (if applicable):

Name of Client/Patient: __________________________________________
Date of Birth: ________________________ Gender: ___________________
Address: ______________________________________________________
Contact No: _________________________

Referral Notes/Comments: _____________________________________________________

____________________________________________________________________________
____________________________________________________________________________

Attachments: ________________________________________________________________

I, _____________________________________ , hereby certify that I have obtained the

necessary consent from the client/patient below above to make this referral. I understand that
this referral may involve the sharing of sensitive information related to the client/patient's
condition and needs.

Client/Patient Name: ___________________________________________________________

I also understand that the information provided in this referral form will be used for the purpose
of assisting the client/patient with their specific needs and will be treated with the utmost
confidentiality in accordance with applicable privacy laws and regulations.

I hereby authorize the release of the information contained in this referral form to the recipient
and any relevant parties involved in the referral process.

[ ] I confirm that the client/patient has provided their consent for this referral.
[ ] I am the legal guardian of the client/patient and provide consent on their behalf.
[ ] I confirm that the client/patient has refused or is unable to provide consent, and I understand
the limitations this may place on the referral process.

_____________________________________ ___________________
Signature over Printed Name Date
 Republic of the Philippines
Bangsamoro Autonomous Region in Muslim Mindanao
Province of Maguindnao
Municipality of Sultan Kudarat Maguindanao Del Norte
Municipal Anti-Drug Abuse Council
Community-Based Drug Rehabilitation Program

Referral Form
Assessment Services – Drug Dependency Exam

Referring Personnel:
Name: ________________________________________________________
Position: ________________________________________________________
Contact No: _____________________ Email: _____________________________

Referral Recipient Information:

Name: ________________________________________________________
Position: ________________________________________________________
Agency: ________________________________________________________

Referral Details:
Reason for Referral: ___________________________________________________
___________________________________________________
Date of Referral:___________________________________________________

Client/Patient Information (if applicable):

Name of Client/Patient: __________________________________________
Date of Birth: ________________________ Gender: ___________________
Address: ______________________________________________________
Contact No: _________________________

Referral Notes/Comments: _____________________________________________________

____________________________________________________________________________
____________________________________________________________________________

Attachments: ________________________________________________________________

I, _____________________________________ , hereby certify that I have obtained the

necessary consent from the client/patient below above to make this referral. I understand that
this referral may involve the sharing of sensitive information related to the client/patient's
condition and needs.

Client/Patient Name: ___________________________________________________________

I also understand that the information provided in this referral form will be used for the purpose
of assisting the client/patient with their specific needs and will be treated with the utmost
confidentiality in accordance with applicable privacy laws and regulations.

I hereby authorize the release of the information contained in this referral form to the recipient
and any relevant parties involved in the referral process.

[ ] I confirm that the client/patient has provided their consent for this referral.
[ ] I am the legal guardian of the client/patient and provide consent on their behalf.
[ ] I confirm that the client/patient has refused or is unable to provide consent, and I understand
the limitations this may place on the referral process.

_____________________________________ ___________________
Signature over Printed Name Date