Referrals

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Make A Referral

Thank you for considering Solid Ground Recovery Centers for your client. We work collaboratively with referral sources to ensure appropriate placement and continuity of care for individuals transitioning into 3.1 residential services.

To fill out a paper copy: download our printable form.

The following items must also be submitted to the Solid Ground Admissions Team as part of the application process:

A copy of the patient’s most recent TB skin test result, or Chest X-ray, TB results or Chest X-ray cannot be more than 12 months old (If applicable).
A recent clinical evaluation such as a Biopsychosocial or Substance Use Disorder Assessment.
A Psychiatric Evaluation and/or History and Physical (if available).
A copy of the patient’s COVID-19 vaccination record (If applicable).

For convenience, you will have the option to upload the files directly to the form, or you can choose to email or fax them separately.

If you have questions about this application or prefer to submit the required documents separately via email, please use the contact info below:

Phone

(240) 750-9663

Email

admissions@solidgroundrecoverycenters.com

Fax

(xxx) xxx-xxxxx

Prescreen Application for Level 3.1 Residential Treatment

Please fill out the form below, completing all sections. If a question does not apply, please type N/A. Once you submit the form, you’ll receive a confirmation email to the email address you provide.

Date

First Name

Last Name

Date Of Birth

SSN:

If currently in treatment, where?

Name of caseworker/counselor/contact person:

Best phone number to contact you or your case worker at this time:

When would you be available to start treatment at Solid Ground? (If you are in treatment right now, what is your discharge date?)

Do you have Medicaid?

MA # (if applicable):

Are you a registered sex offender?

Do you have any pending legal issues at this time? If so, please list them below:

Do you have any active warrants at this time? NOTE: All warrants must be resolved BEFORE an interview can be completed**

What is your primary drug of choice?

When was your date of last use?

How often do you use this substance?

Most recently, how would you use it?

How old were you the first time you used it?

What is your secondary drug of choice?

When was your date of last use?

How often do you use this substance?

Most recently, how would you use it?

How old were you the first time you used it?

What is your tertiary drug of choice?

When was your date of last use?

How often do you use this substance?

Most recently, how would you use it?

How old were you the first time you used it?

The following items must also be submitted to the Solid Ground Recovery Admissions Team as part of the application process: (check which ones you will be uploading to this form)

(If applicable) A copy of the patient’s most recent TB skin test result, or Chest X-ray, TB results or Chest X-ray cannot be more than 12 months old. A recent clinical evaluation such as a Biopsychosocial or Substance Use Disorder Assessment. A Psychiatric Evaluation and/or History and Physical (if available). (If applicable) A copy of the patient’s COVID-19 vaccination record. I will fax or email the applicable items separately (see contact information at the top of this page)

Upload files here:

Best email address to receive confirmation of this form submission

Referrals

Make A Referral

Phone

Email

Fax

Prescreen Application for Level 3.1 Residential Treatment

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