DHS Referral Form

Please contact us at (269) 982-7200 to make a referral or use this form to submit your request. Thanks!

Date of referral:*
Referred by:*
Your phone:*
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Your E-mail:*
Your agency/company:
Client name:*
Client date of birth:*
Service requested:*

5 Panel - Amphetamines, Cocaine, Marijuana, Methamphetamines, and Opiates
7 Panel - The above plus Methadone and Benzodiazepines
10 Panel - All of the above plus Barbiturates, PCP, and Oxycodone

Add ETOH (Alcohol testing)
Service location:*
Client address (if mobile):
Client phone:
-
Additional information:

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