MORR Grant Referral Form

Hartford Healthcare joined Rushford, Hunter’s Ambulance and the city of Meriden to announce a $2 million four-year federal grant to treat addiction through a community approach. The Meriden Opioid Referral for Recovery (MORR) program aims to bridge the gap between the delivery of narcan by first responders to follow-up assessment and treatment that can yield long-term recovery. 

This referral form will help Meriden Department of Public Health and Rushford provide services to the patients that need it. Please complete this form for every naloxone administration or suspected substance abuse patient.

MORR Referral Form for Opioid Recovery

Hunter's Ambulance

(* Denotes Required Fields)

Referrer Information
Name: *
Employee#: *
Client Information
Name: *
Date of Birth: *
Home Address: *
Phone Number: *
Secondary Phone Number:
Reason For Referral
Please Check All That Apply: *	Given naloxone (Fill out section below) Substance use known or suspected Mental health known or suspected Multiple incidents for substance use and/or mental health Family member of an individual with substance use and/or mental health
Naloxone Administration Information
Location/Address of Administration:
Total Milligrams Administered:
Date & Time Administered:
Taken to ED?:	Yes No
If Yes, Where?:
Additional Comments
Please give a brief description of the call: