Programs and Services
Gambling Disorder Treatment
Health & Wellness
Intensive Outpatient Program
HOPE Initiative Program at CODAC
Medical Services
Mental Health
Mobile Unit
Motivational Interviewing
Resources
Substance Use Treatment
Tobacco Cessation
Host Your Next Meeting at CODAC
Our Prescribers
Locations
Cranston
East Bay
Warwick
Newport
Providence
Royal Little
South County
RI Adult Correctional Institution
Donald W. Wyatt Detention Center
Mobile Medical Unit Woonsocket
Mobile Medical Unit South County
Training
News
Careers
About Us
About Us
Mission, Vision, Values
The CODAC Difference
CODAC Leadership
Board of Directors
External Relations
CODAC's Commitment to Research
Contact
CODAC Live
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Intensive Outpatient Program (IOP) Referral Form
client & referral information
client name
Date of Birth
Previous Codac client?
Yes
No
Referral Source
Probation/Parole
Public Defender/Attorney
DCYF
SA Tx Provider
Self (Voluntary)
Other
Referral Contact
Referral Phone
Referral fax
reason for referral
If CODAC patient, please fill out the text fields below.
codac number
codac site and counselor
release to referral source signed
Yes
No
substance use information
current substance use
if not currently using, What is the date of Last use?
in treatment anywhere else?
Yes
No
insurance information
insurance company
member ID
Thank you for your submission.
We will get back to you after our staff reviews your request.
For any further questions, please contact
Cathy Maguire at
(401) 212-4914.
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