Continuum Care Services, Inc. - "Bridging the Gap"
 
Simply complete the referral here to submit electronically 
OR
click the link below to print the Referral Form.  Fax completed forms to 704-720-0670 ATTN: Clinical Director.
Online Referral Form
CONSUMER REFERRAL FORM
Date of Referral
Time of Referral
Hours
 
 : 
Minutes
 
Priority
Emergent/Urgent
Routine
Referring Agency
Referral Made By (include name and title):
Please include agency address, phone number, and email address for follow-up.
REFERRAL INFORMATION
Name:
Date of Birth
Age
Race (optional)
Language (optional)
Physical Address (include city, state, and zip):
County:
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
Outpatient Therapy
Medication Management
Insurance Information
Medicaid
Medicare
Private/Commercial Insurance (i.e. BCBS)
Self-Pay/Uninsured
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.
Yes
No
The person for whom you are making this referral is willing to participate in an assessment and treatment recommendations.
Yes
No
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
Aggressive animals/pets
Weapons in the household
Frequent psychotic episodes
Hostility toward a particular race or sex
None
Primary Care Physician Information
Physician Name:
Name of Practice:
Practice Address:
Daytime Phone Number:
After-hours Phone Number: