Washington State 4D Service Referral Form
4D Recovery provides substance use recovery support services for individuals ages 18–35. This referral form may be completed by an agency or by an individual seeking recovery support. A brief self-assessment is included to help determine whether 4D’s services are a good fit. All information shared on this form will remain confidential and will only be used to help connect you with recovery support services.
4D Service Overview
4D offers drop-in recovery support at each of our centers. These services are open to anyone seeking recovery support and include 12-step meetings, recovery events, and skill-building groups. Additionally, we provide free peer support services for young adults ages 18–35 living in Clark County.
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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Clark County
What type of 4D recovery support do you need?
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Peer Support (someone in recovery who helps you find/sustain recovery)
Mutual-Aid Recovery Support (12 Step and other types of recovery meetings)
Other
What, if any, other services would you like to be connected to?.
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Detox
Substance Use Treatment
Mental Health Treatment
Housing
Employment
Education
Primary Care
Dental
Other
Contact Information
Please provide the contact information of the person being referred
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.
Format: (000) 000-0000.
Individual's Age
*
Individual's Email
*
example@example.com
Individuals Address
*
Referring Agency Information (if applicable)
*
Example: Volunteers of America-Men's Residential Center
Anything else we should know?
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Submit
Should be Empty: