referral form

ARJ takes walk-in appointments. In addition, we have developed a referral screening form that the referral source is asked to complete and return to ARJ staff so that services can be initiated. ARJ staff makes the commitment to initiate contact/services with consumers within 24 hours of receiving referral information. Determinations on appropriate service are based on the initial assessment conducted by our team of licensed clinicians. Admission to service is based on the assessment as well as the state developed entrance criteria for the specific service.

Please complete and print out this form and fax to our secure lines:

  • Charlotte, NC: (980) 819-5694
  • Greensboro, NC: (336) 763-0316
  • New Orleans, LA: (504) 324-8692

Or feel free to call one of the offices to have your referral completed with the assistance of one of our live intake specialist.

Download PDF.