P & P Home Services, LLC
PO Box 441730
Indianapolis, IN 46244-1730
317.300.1368
DA@PPHomeServices.com
Please fax referral to 317-300-1369
Drug and Alcohol Screening Referral Form
Date of Referral:
Agency Name:
Person submitting referral: (Private pay referral?) Yes No
Email Address:
Participant Information
Name:
Address Phone
Number of Screens:
1 Collection
6 Collections
12 Collections
Other
Are Screens to be Random? Yes
No
Duration of Screens
Once
Daily
Weekly
Monthly
Other
Is this screen for employment? Yes
No
If yes, Employer:
Address Phone Number
Additional information: