Simply complete the referral here to submit electronically
lick the link below to print the Referral Form. Fax completed forms to 704-720-0670
ATTN: Clinical Director.
PRINT REFERRAL FORM TO FAX
Online Referral Form
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CONSUMER REFERRAL FORM
Date of Referral
Time of Referral
Referral Made By (include name and title):
Please include agency address, phone number, and email address for follow-up.
Date of Birth
Physical Address (include city, state, and zip):
Evaluation Requested for the following service(s)
Child/Adolescent Mental Health
Child/Adolescent Substance Abuse
Adult Mental Health
Adult Substance Abuse
Comprehensive Clinical Assessment only
Private/Commercial Insurance (i.e. BCBS)
Policy Number(s)/Medicaid ID Number:
Parent or Legal Guardian (if applicable):
Primary Phone Number
Secondary Phone Number
Name of Emergency Contact and Phone Number:
OTHER HOUSEHOLD MEMBERS AND RELATIONSHIP:
Include the name(s), sex, age, relationship of others in the household.
REASON FOR REFERRAL
Please provide specific information of precipitating events that led to this referral.
The person for whom you are making this referral is aware of the referral.
The person for whom you are making this referral is willing to participate in an assessment and treatment recommendations.
Unsure, seeking additional information.
Are there any potential staff safety risks (select all that apply)?
Neighborhood safety risks
History of suicidal thoughts/attempt
History of homicidal thoughts/attempts
Weapons in the household
Frequent psychotic episodes
Hostility toward a particular race or sex
Primary Care Physician Information
Name of Practice:
Daytime Phone Number:
After-hours Phone Number: