Rogue Recovery Mentor Referral Form

Rogue Recovery Mentor Referral Form

True Colors provides substance use recovery support services to individuals within Josephine County that are 18 years of age and older. This form can be completed by either an agency or a person seeking recovery support. We have provided a short self-assessment that will help interested parties determine if True Colors services will be an effective choice.
Rogue Recovery Service Overview

Rogue Recovery has drop-in support at our location at 550 SW 6th St Suite F Grants Pass, Oregon. These services are open to anyone wanting recovery support and they include 12 step meetings, recovery events and skill building groups. We also offer free recovery mentor services to adults in Josephine County.
Service Assessment
Generally, people wanting to engage in our services meet at least one of the following criteria. If none of these apply to you, then Rogue Recovery Center services are not likely to meet the need you are trying to address. Please check all that apply.*

Using drugs and/oralcohol is causing issues in my life and I want to stop it from happening.I want to stop using drugs and/or alcoholI am being pressured to address my drug and/or alcohol use by someone/something else (friends/family/court/school/employer/etc.)Rogue Recovery Center is being suggested by a social service providerI am unsure if drug and/or alcohol use is a problem for me, but I am interested in learning more about what recovery is.Other
If you answered yes to any of the previous statements, please continue.
Do you live in Josephine County?*
What type of services would you like to participate in at Rogue Recovery?*

Recovery Mentoring (someone in recovery who helps you find/sustain recovery)Mutual -Aid Recovery Support (12 step and other types of recovery meetings)I am wanting more information
Have you experienced any of the following within the last 6 months*

Hospitalized due to alcohol or substance useExperienced an overdoseHave developed medical issues due to use.no
Are you being referred to services to comply with deflection or a court order?*

yesno
What, if any, other services do you think you need?*

DetoxResidential TreatmentMental Health TreatmentHousingEmploymentEducationPrimary CareInsuranceDentalHep C/ STD TestingHarm ReductionOther
Individuals Name*

First NameLast Name
Gender
Phone Number*
Please enter a valid phone number.
Individuals Age*
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Agency (if applicable)
Anything else we should know?*
Should be Empty:

Rogue Recovery Mentor Referral Form

Rogue Recovery Service Overview

Service Assessment

If you answered yes to any of the previous statements, please continue.