| Mental Health Court Drug
Testing Referral Form |
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| Client Name: |
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Court Case #: (JD, CM, CF) |
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| Client Phone: |
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KK#: (DHS, CW Only) |
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| Referral Name: |
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Referral Phone: |
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| Referral Email: |
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| Drug Screening Program Options:
(Check all that apply) |
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One time
Urinalysis Test: |
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One Panel: |
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Drug Requested: |
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5 Panel: (Results in 24-48
Hours) |
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(5 panel
test - THC, cocaine, amphetamine, opiates, methamphetamine &
benzodiazepines) |
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Hair Follicle:
(Results in 2-3 Days) |
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(Hair Follicle Testing can
detect regular drug use over a 90 day period, 5-panel test -
cocaine, amphetamines, opiates, thc, & pcp) |
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Random
Urinalysis Testing: |
| Random Schedule will consist of
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tests per month for
month(s) |
| OR... |
tests per week for
month(s) |
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| Do you want the client to
test?: |
5-days
(M-Fri) a week, or
7-days
(M-Sun) a week. |
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One Panel: |
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Drug Requested:
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5 Panel: (Results in 24-48
Hours) |
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(5 panel
test - THC, cocaine, amphetamine, opiates, methamphetamine,
& benzodiazepines ) |
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ETG + 2 Panel: (Results in
24-48 Hours) |
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Drug Requested: |
Drug Requested:
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Hair Follicle:
(Results in 2-3 Days) |
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(Hair Follicle Testing can
detect regular drug use over a 90 day period, 5-panel test -
cocaine, amphetamines, opiates, thc, & pcp) |