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: Melissa@activerecoveryla.org

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

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

Thank You!