Know of someone in need of our services for substance use or problem gambling? Connect with our team. The required information differs slightly based on your relationship to the prospective patient.
Select your scenario below to complete the appropriate secure form.
Submit a Referral
You can securely email info@asac.us the following information to refer a patient:
Providers & Social Workers
- Patient’s name
- Patient’s date of birth (DOB)
- Working phone number for patient
- Patient’s address
- Release of information for referring agency
- Level of recommended care
- Including current ASAM supporting recommended level of care
- Substance use history
- Requested program or location for referral
Parents & Teachers
- Referrer’s full name
- Referrer’s working phone number
- Patient’s name
- Patient’s date of birth (DOB)
- Working phone number for patient
- Patient’s address
ASAC offers medication-assisted treatments (MAT), onsite or through linkages at all locations.
ASAC is committed to fostering an inclusive environment where all individuals have access to services and everyone—patients, staff, and community members—feels a sense of belonging.