Client Referral Form
Controlled Substance Abuse Program (CAPS)
Client Name: __________________________________________
Contact Person: __________________________________________
Address: __________________________________________
__________________________________________
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Telephone: __________________________________________
Fax: __________________________________________
Your Client’s Name: ______________________________________
Previous Name: ______________________________________
Date of Birth: ______________________________________
Address: ______________________________________
______________________________________
_______________________________________
_______________________________________
Driver’s License #: _______________________________________
Medications that you may believe that the Client is taking at this time:
________________________________________
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________________________________________
________________________________________
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We, ____________________________ agree to retain Controlled Substance Abuse Program (CAPs) for the purpose of obtaining a Urine Drug Screen, a Michigan Automated Prescription Report (MAPS), and interpretation of the above mentioned data.
Name: _______________________________________________ Date: __________________
Thank you for retaining the Controlled Substance Abuse Program (CAPs) for your information needs. We look forward to providing you with the most accurate data that is available to ensure that any and all controlled substances that your client is taking are accounted for and are shown to be used in an appropriate fashion.
For the ease of your client, we have found this laboratory to be the closest to their address, as you have provided on the intact form:
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The hours for this particular laboratory are as follows:
Monday _________________________
Tuesday _________________________
Wednesday _________________________
Thursday _________________________
Friday _________________________
Saturday/Sunday: Closed
Appointment time:
The client may go to the laboratory at any time they are open during the week
of _____________________________________________________________.
If they do not show up for their appointment, a $100 administrative fee is assessed.
