SUBSTANCE ABUSE SERVICES INITIATIVE (SASI) National Guard

Referral Form

*Date: ______Voucher Number: ______

*Service Member’s Name:______*SS #:______*DOB:______

*Rank: ______*Unit: ______

Address: ______Phone Number(s) Home: ______Cell Number:______

*Reason for screening referral: Self-referral? ___YES ___ NO *Drug(S) of Choice______

*(+) Drug Screen? _____ YES _____ NO * List Drug(s) detected: ______Date of UDS: ______

Provider Chosen (See below):______

Scheduled Screening Date: ______Time: ______

Notified Provider of Referral: ____ NO ____ YES Spoke with: ______

*Required for data collection purposes Revised: 9/4/2013

SUBSTANCE ABUSE SERVICES INITIATIVE (SASI) Louisiana National Guard

Metropolitan Human Services District (/Arabi)

Treatment Provider Address Phone Hours of Point of Contact Provider Operation Chosen: (Client initials in box)* ACER, LLC – 7532 W. Judge Perez Dr. 504-682-9550 M-TH: Emily Dileo Arabi Arabi, LA Fax: 504-682-9899 8:30am-9pm [email protected] Erin Gousman [email protected] Greenpath Addiction & 411 S. Broad St 504-827-2928 M-F: Earnest Airhia Mental Health Services New Orleans, LA Fax: 504-827-2926 9am-6pm [email protected] – New Orleans Jacqueline Meyers: [email protected] Celebration Hope 7500 W. Judge Perez Dr. 504-833-4673 M, Tues, & Thurs: Carissa Mitchell: Center (Healing Arabi, LA Fax: 504-885-0400 4:30pm-8:30pm [email protected] Hearts)– St. Bernard Jackie Miller: [email protected]

Baton Rouge Area Providers:

Treatment Provider Address Phone Hours of Operation Point of Contact Provider Chosen: (Client initials in box) Bethlehem Baptist Drug 2274 Wooddale Blvd. 225-928-1088 M, Tues, & W: Patrice Butler: Treatment Program Baton Rouge, LA Fax 225-932-9488 9am- 7:30pm [email protected] Thurs: 9am-5pm Carol Anderson F: 9am-1pm [email protected]

Cenikor Foundation 2414 Bunker Hill Dr. 225-218-1960 M-F: Kyllie Jenkins: Baton Rouge, LA Fax: 225-218-1969 8am-5pm [email protected] . O’Brien House 446 North 12th St. 225-344-6345 M-F: Emily George: [email protected] Baton Rouge, La Fax: 225-344-0119 8am-4pm Aimee Bates [email protected]

*Required for data collection purposes Revised: 9/4/2013

SUBSTANCE ABUSE SERVICES INITIATIVE (SASI) Louisiana National Guard

South Central LA Human Services Authority (Franklin):

Treatment Provider Address Phone Hours of Operation Point of Contact Provider Chosen: (Client initials in box)* SRF Consulting 524 Martin Luther King 337-828-7390 Tues & Thurs: Sheron R. Steward: Jr. Blvd. Fax: 337-413-1106 8:30am-5:30pm [email protected] Franklin, LA W: 8:30am-6:00pm

Lafayette Area Providers(Lafayette/ New Iberia/Ville Platte):

Treatment Provider Address Phone Hours of Operation Point of Contact Provider Chosen: (Client initials in box) Recovery 401 W. Vermilion St. 337-236-5446 M-F: Claudette Blackburn: Center Lafayette, LA Fax: 337-524-1420 8am-4:30pm [email protected]

`Glove Incorporated 802 N. Dupre St., 337-363-4758 M-F: Nelson Washington: Ste. 34 Fax: 337-363-4760 8am-5pm [email protected] Ville Platte, LA Keys for Sober 132 West St. Peter 337-364-9094 M-Thurs: Living St. Fax: 337-364-9071 8:30am-8:00pm Dr. Joseph Wilson: New Iberia, LA Friday: [email protected] 8:30am-4:30pm

Imperial Calcasieu Human Services Authority (Lake Charles)

Treatment Provider Address Phone Hours of Operation Point of Contact Provider Chosen: (Client initials in box)* Imperial Calcasieu 4105 Kirkman Street 337-475-8022 M-F Diane Fruge Human Svs. Authority Lake Charles, LA 70607 8AM -4:30 PM [email protected]

Allen Behavioral Health 402 Industrial 337-639-3001 M-F Sheryl Muwwakkil Oberlin, LA 8AM -4:30 PM [email protected]

*Required for data collection purposes Revised: 9/4/2013

SUBSTANCE ABUSE SERVICES INITIATIVE (SASI) Louisiana National Guard

Beauregard Behavioral 106 West Port St. 337-462-1641 M-F Sheryl Muwwakkil Health Clinic Deridder, LA 8AM -4:30 PM [email protected]

CENLA Chemical Dependency Council (Alexandria)

Treatment Provider Address Phone Hours of Point of Contact Provider Operation Chosen: (Client initials in box)* CENLA Chemical Central La. State Hospital 318-484-6778 M-F Kathy Pflipsen Dependency Council Grounds, Fax 866-407-1152 8 am- 4:30 pm [email protected] Lincoln St., Unit 24, Ulysses Frank [email protected] Pineville, La. 71360

Northwest LA Human Services District (Shreveport/Natchitoches/Minden)

Treatment Provider Address Phone Hours of Point of Contact Provider Operation Chosen: (Client initials in box)* Northwest LA Human 1310 North Hearne Ave. 318-676-5111 M – TH Beverly Parnell Services District Shreveport, LA 8AM – 8 PM [email protected] F 8AM- 4:30 PM Natchitoches Office 210 Medical Drive, 318-357-3122 M-F Josie Hamilton of Behavioral Health Natchitoches, LA 71457 8AM -4:30 PM [email protected]

Minden Behavioral 435 Homer Road 318-371-3002 M-T Sammy Robinson Health Minden, LA 71055 8am – 7 pm [email protected]

W-F 8AM – 4:30 PM

Monroe Area Providers (Monroe/Ruston):

Treatment Provider Address Phone Hours of Point of Contact Provider Operation Chosen: (Client initials in box)

*Required for data collection purposes Revised: 9/4/2013

SUBSTANCE ABUSE SERVICES INITIATIVE (SASI) Louisiana National Guard

Family Life 829 E. Georgia St., Ste. 318-237-8544 Alphonso Bingham Development Center 5 Fax 318-255-6555 [email protected] Ruston, LA Horizon Rehab 2911 Cameron Street 318-651-9363 M-F Kerry Scott Center Monroe, LA 71201 Fax 318-651-9251 8 am – 4:30 pm [email protected]

Rays of Sonshine 616 North 3rd St. 318-323-0502 M-F: Claire White: Monroe, LA Fax:318-387-0700 8:30am-4:30pm [email protected] Lynn Daniel: [email protected] River City 800 Washington St., 318-325-8782 M-W: Professional Ste. B-2 Fax: 318-325-8749 8:30am-7pm Thurs Deborah Doublin: Counseling Services Monroe, LA & F: [email protected] 8:30am-6pm Saturday: by appointment

Jefferson Parish Human Services Authority (Metairie/Kenner/Gretna)

Treatment Provider Address Phone Hours of Point of Contact Provider Operation Chosen: (Client initials in box)* ACER, LLC – Metairie 2901 Ridgelake Dr., 504-941-7580 M-TH: Allison Ste. 106 Fax: 504-941-7585 8:30am-9pm Kocsis: [email protected] Metairie, LA Lori Morris: [email protected] Celebration Hope 1901-B Airline Dr. 504- 833-4673 M-Thurs: Carissa Mitchell: Center (Healing Metairie, LA Fax: 504-885-0400 8:30am-8:30pm [email protected] Hearts) – Metairie Friday: Jackie Miller: 8:30am-4:30pm [email protected] Gateway Recovery 4103 Lac Couture Dr. 504-368-9935 M-F: Darryl Chandler: Systems Harvey, LA Fax: 504-368-9918 7am-7pm [email protected]

Greenpath Addiction 1919 Veterans Blvd., 504-466-1413 M-F: Jacqueline Meyers: & Mental Health Ste 307 Fax: 504-466-1293 2pm-6pm [email protected] Services – Kenner Kenner, LA Senora Perkins [email protected] Responsibility House 1799 Stumpf Blvd 504-367-4234 M-Thurs: Monica Rose: Building 1, Suites 2&4 Fax: 504-367-4237 8am-8pm [email protected] Gretna, LA Friday: Jeremy Horn: 8am-4pm [email protected]

*Required for data collection purposes Revised: 9/4/2013

SUBSTANCE ABUSE SERVICES INITIATIVE (SASI) Louisiana National Guard

Florida Parishes Provider (Slidell/Covington)

Treatment Provider Address Phone Hours of Point of Contact Provider Operation Chosen: (Client initials in box)*

ACER, LLC – Slidell 2238 First St. 985-690-6622 M-TH: Emily Dileo Slidell, LA Fax: 985-690-6662 8:30am-9:00pm [email protected] Friday: Erin Gousman 8:30am-3pm [email protected]

Freedom of choice means having options for screening/assessment/brief intervention, being informed of different choices and being able to choose freely without being pressured by other people. By signing this form, I acknowledge that the freedom of choice has been discussed with me, the different service options available, and that I have freely chosen the provider for recommended services. I understand that my attendance and participation in this service is a contingency for my retainment in the National Guard.

Service Member’s Signature: ______Date: ______

LA ARNG Representative: ______Date: ______

*Required for data collection purposes Revised: 9/4/2013