Referral – Drug / Alcohol Assessment Referral - Drug / Alcohol Assessment Date * Name * Name First Name First Name Last Name Last Name Reason for Assessment: * Use or possession of alcohol/other drugs or drug paraphernalia and/or under the influence of alcohol/other drugs or unauthorized drugs/substances. Sale or distribution of alcohol/other drugs OtherOther Additional comments pertaining to referral: Name of Staff: * Title: * Preferred method of contact: * Email Fax Email: * Fax: * Submit completed referral to Palmer. Fax: 918-292-8250 Email: programs@palmer-tulsa.org Information Pertaining to Assessment The patient must contact Palmer Office to schedule an assessment appointment. If the patient is a minor, a parent or legal guardian must make the appointment. The type of assessment completed will depend on the patients age: Adult: ASI Assessment / Adolescent: CAR Assessment. There is no cost to the patient for the assessment. Legal guardians must bring proof of guardianship to the appointment. The expected time for a full assessment is approximately 2 ½ to 3 hours. Upon completion of assessment, the patient will be referred to Tulsa Drug Screening Inc. (TDS) for a urine drug analysis. This cost of the drug test is $16.00, payable directly to TDS. Financial assistance is available for the drug test but only applies to minors under the age of 18. Attendance letters for school and work can be provided upon request. Palmer Outpatient Services (Southeast corner of 8th and Denver) 222 W 8th St, Tulsa, OK 74119 918.832.7763 www.palmer-tulsa.org Submit If you are human, leave this field blank.
