Complete a Referral Form
Know of someone in need of our services for substance use or problem gambling? Connect with our team through our online referral form.
Submit a Referral Email
The required information differs slightly based on your relationship to the prospective patient.
Select your scenario below and securely send the information below to the email provided.
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
Jones County Referral Form
If you are affiliated with Jones County Law Enforcement, please complete the Jones County Law Enforcement Referral form linked below.
Note: This form is exclusively for use by authorized Jones County Law Enforcement personnel. Submissions from individuals or entities outside of Jones County Law Enforcement are not permitted.
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.