GET STARTED WITH AVALON

Fax Referral Form

Use the same referral form for any Avalon service, including counseling, Intensive Outpatient Program (IOP), medication management, and medication-assisted treatment (MAT).

You can use this process to refer yourself or someone else.

Fillable PDF: best for most people. Type into the fields, check the boxes, then save or print. The one-page layout stays fixed. If the fields do not work in your browser, download the PDF and open it in a PDF reader.

Editable Word form (.docx). Choose this version if you prefer working in Microsoft Word. You can type and edit the document, but formatting may shift as you add text. Its checkboxes are not interactive controls.

How to make a referral

1. Download the form

Choose the fillable PDF or editable Word form above. Both contain the same referral information.

2. Complete the form

Fill out the referral form before sending it to Avalon.

3. Fax it to Avalon

Fax the completed form to 207-777-4649.

Need help with a referral?

You can also call our main office at 207-333-1080 to discuss a referral or ask about next steps.

The Contact us form is for general, non-clinical questions only and is not HIPAA-secured. Do not send patient details, private health information, or completed referral forms through it.