Date of Referral *

MM

DD

YYYY

Referred by:

Clinic

Doctor

Family/Friend

Behavioral Health Provider

Self

Other

Member Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Race

American Indian/ Alaskin Native

Black/ African American

White

Asian

Native Hawaiian/ Pacific Islander

Hispanic/ Latino

Other

*

Title XIX

ACC

Non-Title XIX

Other

Phone *

(###)

###

####

Cross System Involvement:

DDD - Division of Developmental Disabilities

Probation

DCS - Department of Child Safety

Parole

ALTCS - Arizona Long Term Care Services

Doctor's Name:

First Name

Last Name

Doctor's Phone

(###)

###

####

Guardian's Name:

First Name

Last Name

Guardian's Phone:

(###)

###

####

Office Phone:

(###)

###

####

Areas of interest to the member: *

Peer Support

Group Counseling

Young Adult Program (Ages 18-25)

Recovery Focused Groups

Opioid Support Groups

Transportation

Discharge Care Coordination

Independent Living Skills

Health, Wellness & Excercise

Individual Counseling

Job Skills

Location of interest to member:

S.T.A.R. Central (Phoenix)

S.T.A.R. East (Mesa)

S.T.A.R. West (Avondale)

S.T.A.R. North (FlagStaff)