DART Referral

If this is a life threatening Emergency or crisis, please call 9-1-1.

This form is to be used to submit a Referral to DART, Drug Addiction Recovery Team. A Community Responder will reach out to the person being referred within 72 hours.

You may also reach us by telephone or text at 413-588-2335.

To Continue, plesae complete form below and Submit.

Referred By

NOTE: All submitter's information is confidential and is not shared with any parties. If you are not the Person being
Referred, to follow-up or if you have questions, you will need to contact us by telephone at 413-588-2335.

Referred By Role (if not Self) (required)

Referred By First

Referred By Last (required)

Referred By Home Phone

Referred By Cell Phone

Referred By Email

Person Being Referred

Referred First Name

Referred Last Name (required)

Referred Alias

Street Address

Unit/Suite

City

State

Zip Code

Home Phone (required)

Date of Birth

Gender

Gender Other

English Speaking

Primary Language

If Other language

Hispanic/Latino/a

Race

If Other Race

Pronouns

Other Pronoun

Veteran Status

Currently Houseless