4D Service Referral Form
4D provides substance use recovery support services to people between the ages of 18-35. 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 4D services will be an effective choice.
4D Service Overview
4D has drop-in support at each of our recovery centers. 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 young adults 18-35 who live in Multnomah, Washington, and Clackamas Counties.
4D Recovery Service Assessment
Generally, people wanting to engage in our services meet at least one of the following criteria. If none of these these apply to you, then 4D services are not likely to meet the need you are trying to address. Please check all that apply.
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Using drugs and/or alcohol is causing issues in my life and I want to stop it from happening.
I want to stop using drugs and/or alcohol.
I am being pressured to address my drug and/or alcohol use by someone/something else (friends/family/court/school/employer/etc.).
4D is being suggested by a social service provider.
I 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.
4D Service Request
What area would you like to receive services in?
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Washington County
Multnomah County
Clackamas County
You Selected Clackamas, this is a:
General Referral
Law Enforcement Referral
Lines for Life Referral
Prime Plus Health Care Referral
You Selected Multnomah County, this is a:
General Referral
Closed Street Referral
What type of 4D recovery support do you need?
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Recovery Mentoring (someone in recovery who helps you find/sustain recovery)
Mutual-Aid Recovery Support (12 Step and other types of recovery meetings)
Substance Use Treatment
Mental Health Treatment
Other
Contact Information
What, if any, other services do you think you need.
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Detox
Residential Treatment
Mental Health Treatment
Housing
Employment
Education
Primary Care
Dental
Other
Individual's Name
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First Name
Last Name
Individuals Gender
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Individual's Phone Number
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If the individual does not have a phone number, please fill form out with contact info the individual can provide.
Individual's Age
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Individual's Email
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example@example.com
Individuals Address
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Referring Agency Information (if applicable)
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Example: Volunteers of America
Anything else we should know?
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Submit
Should be Empty: