AGENCY REFERRAL

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This form is for providers and other agency referrals only. Please do not use this form if you are the client.

INSTRUCTIONS: STEP 1-Please submit the form below to refer your agency's client to Teras.

STEP 2-Use the myfax button to the right to upload and fax digital documents (pdf's) securely to Teras. THE MYFAX BUTTON ONLY ACCEPTS ONE PDF document per submission.If you have multiple documents that can't be consolidated into one-use the fax number above the button 503-715-5672 and send through your fax machine.

Thank you for referring to Teras!

Referral Form

Disclaimer: Completion of an outpatient treatment program for addiction, domestic violence or anger management is not a Teras Outpatient Program endorsement the person completing will be violence or other high risk behavior free. Reports of progress are primarily based on client self report and clinician observations in the treatment setting only. Teras group facilitators and clinicians are not licensed psychologist or medical doctors and will not be accepted as expert witnesses in a court of law. Violence, driving under the influence and abusive anger are always a choice. A completion certificate is not admissible in court as evidence one is "cured" of the abusive or risky behavior, will be safe to parent, drive a vehicle or remain in an abuse free relationship.

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AGENCY REFERRAL

Referral Form