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Referral Letter

PLEASE USE THE FOLLOWING GUIDELINES TO WRITE YOUR REFERRAL LETTER


Readiness for Healing Program:

A – Present emotional health

B – Why now?

C – Previous Treatment or Healing Program?

Alcohol and Drug History

Relationships

What resources does Applicant have?

Healing Program Goals?


Referred by:

Name:

Address:

Telephone:

Relationship to Applicant:

  • Employer

  • Counsellor

  • A.A., Sponsor

  • Physician

  • Probation Officer

  • Other (Specify)