Charles Lea Center Referral Form (NC)

Charles Lea Center Referral Form
Information of Person served
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email Address
example@example.com

Current Residence Type: (i.e. apartment, group home, family home):
Does this person currently receive services from any other provider? If yes please list provider and what services received:
Funding Source (i.e. Innovations, State Funded, Grant, Private Pay):
Information of family/guardian (if applicable)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email Address
example@example.com

Care Coordinator
Name

First NameLast Name
Cell Phone Number

Area CodePhone Number
Email Address
example@example.com
If any other information is needed, please list the appropriate person for us to contact. Be sure to include preferred method/time of contact and any phone numbers associated. This could be the person themselves, guardian, staff, etc.:

Desired Outcomes
Describe the desired outcome of the person being served:
Do they currently use any technology to support daily living:

YesNo
if Yes, please explain:
Does the desired outcome include a change of residence:

YesNo
Is there a specific time frame for reaching the desired outcome:

YesNo
if Yes, please explain:

Informed Consent

By signing below, I consent The Charles Lea Center may use the information provided on this
form and communicate with other members of my circle of support team in order to reach my
desired outcome. I consent to the release of any pertinent documentation regarding my
support needs, diagnoses, and level of care. This information will be used by The Charles Lea
Center to make recommendations for services and possibly the use of technology to reach
desired outcomes. It does not guarantee that desired outcomes will be met.
Signature/Mark:

Clear
Date

MonthDayYear
Parent/Guardian Signature:

Clear
Date

MonthDayYear
Form Completed By:

Clear
Date

MonthDayYear
**This consent is valid for 1 year from the date signed**
Should be Empty: