Refer a Patient for Alcohol Use Disorder Care

This form is not for urgent or emergency situations. Referrals are reviewed during business hours and are not monitored continuously. If your patient is in acute alcohol withdrawal, medically unstable, or at risk of harm to themselves or others, direct them to emergency care now — call 911, send them to the nearest emergency department, or call or text 988 for the Suicide & Crisis Lifeline. Do not use this form to communicate a clinical emergency.

Referral received

Thank you. Our team will reach out to your patient to schedule an evaluation, and will confirm receipt with you. Clinical assessment — including withdrawal risk and whether outpatient care is the appropriate level — is completed at intake by the treating provider.

Patient

Enough for us to make contact and confirm eligibility.

First name *

Last name *

Phone *

State of residence *

Insurance

Referring provider

So we can confirm receipt and close the loop with you.

Your name *

Organisation / practice

Your email *

Your phone

Referral detail

Brief context only. Full clinical assessment happens at intake.

Reason for referral *

Please keep this brief and avoid sending records through this form.

Timeframe

This helps us prioritise outreach. It is not a triage channel — see the notice above.

Known withdrawal history

If known, this helps the treating provider plan a safe start. It does not change how quickly this form is reviewed.

Consent

I confirm the patient is aware of and has consented to this referral, and that I am authorised to share the information above for the purpose of arranging care. *

I confirm this is not an emergency or an acute withdrawal situation, and that I will direct the patient to emergency care if it becomes one. *

What happens next The referral is entered into our EMR and our team contacts the patient to schedule an evaluation, confirming receipt with you. Withdrawal risk, level-of-care suitability and medication appropriateness are assessed at intake by the treating provider — this form makes the introduction, it is not a clinical triage channel.

Information submitted here is used to arrange care and is handled in line with our privacy practices. Please do not attach or paste clinical records. EnnHealth provides outpatient telehealth care in the states where it is licensed and is not a detox, inpatient or emergency service.

Refer a patient for AUD care

Referral received