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)