Referral and Screening Form

Please fill out the form below via the "Click Here" button. Once complete, please fax or email form to:

Shreveport Fax: 318-216-5868
Shreveport Email: Shreveport@activerecoveryla.org

Bossier Fax: 318-584-7135
Bossier Email: Bossier@activerecoveryla.org

Minden Fax: 318-377-9283
Minden Email: Minden@activerecoveryla.org

Thank You!