SUBSTANCE USE & MENTAL HEALTH REFERRAL FORM

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PCRS provides substance use and mental health services that meet participants where they’re at, recognizing that participants have different relationships with substance use. With compassion and professionalism, we approach participants to help them see who they truly are outside of their addiction. We believe in striving to help them to live healthy, thriving, empowered lives.

To apply for substance use related support, please select your region, program of interest and continue to the next page.  The following application will ask for your basic information.  After submitting this form, you can expect that someone from our team will reach out to you with next steps.


This is a gated program that receives referrals from MCFD SW, CYMH Clinician, or probation officer only.


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Name





Basic Information









Home Address





Email Address and Phone Number




Emergency Contact Information




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Youth Substance Use and Medical Information
The following information will be useful for us to review; however it is not required to fill out the following section at this stage.
Please List Substances of Concern


Youth Justice Information (if applicable)
Criminal Justice Involvement 



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Referral Information











Comments (if applicable)