Referral Information

Referral Form

Please take a moment to complete the referral form below. A Reach for Recovery team member will reach out to you promptly upon receiving your form.

Today's Date and Time

Full Name

Relationship to Client

Email

Phone Number

Full Name

Date of Birth

Parent Name(s) If Applicable

Address

State

Zip Code

County

Is the Client Pregnant

Insurance Provider

Insurance Type

Plan Number

Group Number

Insurance Provider's Contact Name

Insurance Provider's Contact Phone Number

Relevant Substance Abuse and Family Information

483 Century Lane
Holland, MI 49423

700 Washington Ave., Suite 220
Grand Haven, MI 49417

both Reach out-patient locations are handicap accessible.

a 501(c)3 addiction recovery nonprofit