Referral Form – Substance Use Disorder

Instructions

Substance Use Disorder classes are designed for those who may have an issues with using drugs.

Please fill in all the form fields as accurately as possible. If there is missing or incomplete information, it may cause a delay in processing your referral information.

You have two options to submit a referral to us.

  • It can be printed, completed and faxed to 410-220-0730. ATTN: Ms. Wise

Click Here to Print

  • Fill in the form to the right and submit it through our secure website

For questions about completing this form or inquiries about our services please call 410-617-8026 x 0 or email essentialinfo@ebhsinc.com and a program representative will reply within 1 business day.







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Form

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