Opiate Response Team Referral Form

*Name of Person Making Referral:

Relationship to Client:

*Client First Name:

*Client Last Name:

Date of Birth:

*Address:

*City:

*State:

*Zip Code:

*Phone:

Family/ Significant Other Information:

Family/ Significant Other Phone:

Date of Overdose:

Location of Overdose:

*Was immunity letter given to client?:

Other Information:

*Security Key: