Client Referral Form

Controlled Substance Abuse Program (CAPS) 

Client Name:       __________________________________________

Contact Person:  __________________________________________

Address:               __________________________________________

                              __________________________________________

                              __________________________________________

                              __________________________________________

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:

                                    ________________________________________

                                    ________________________________________

                                    ________________________________________

                                    ________________________________________

                                    ________________________________________

                                    ________________________________________

                                    ________________________________________

 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:

 _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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.

 

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