Referring Agency Office Information

Referred Client/Patient Information

Insurance

Reason For Referral

Primary Mental Health Diagnosis

Medical Diagnosis (if applicable)

Drug Addiction

Has Client tried to quit using a substance?

Is Client active in his/her addiction?

Does Client smoke cigarettes?

Does Client drink alcohol?

Is there a history of Suicide/homicide Ideation?

Court Involvement

Other Agency Involvement

 

Out For Good, Inc.

Schedule your appointment

Christopher E. Conway, M.Ed., LADC-1

Tel. (617) 980-8835

Fax (617) 708-0296

info@outforgoodinc.com

OFFICE

1773 Dorchester Avenue

Unit #2C

Dorchester, MA 02124

2020 Out For Good, Inc.