MAIL-IN or FAX-IN REFERRAL FORM
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OR

TELEPHONE NUMBERS:
Treatment ~ (337) 233-8115
Administration~ (337) 233-8114
FAX ~ (337) 233-8122

MAIL TO:
St. Francis Foundation
P.O. Box 5148
Lafayette, La. 70506

TELEPHONE REFERRALS MUST BE MADE BY THE COUNSELOR~~~REFERRALS MUST BE COMPLETED BY THE COUNSELOR
TELEPHONE REFERRALS MUST BE MADE BY THE COUNSELOR
REFERRALS MUST BE COMPLETED BY THE COUNSELOR

1. COMPLETE FORM.  DO NOT LEAVE ANY BLANKS.  INCOMPLETE FORMS & MISSING AND/OR INCOMPLETE TREATMENT INFORMATION WILL CAUSE CLIENT TO BE REMOVED FROM THE WAITING LIST.  

2. CALL ST. FRANCIS AND PUT CLIENT ON THE WAITING LIST.

3. MAIL OR FAX IN THIS FORM WITH THE FOLLOWING TREATMENT INFORMATION: 

   • PSYCH-SOCIAL

   • HISTORY & PHYSICAL

   • ANY PSYCHOLOGICAL TESTING

   • DISCHARGE SUMMARY OR PROGRESS REPORT

4. YOU MUST INFORM CLIENT THAT THEY MUST CALL ST. FRANCIS EVERY WEEK AFTER DISCHARGE TO REMAIN ON THE WAITING LIST.

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