Referral Form
County the client lives in:
*
Mecklenburg County
Union County
Rowan County
Gaston County
Cabarrus County
Other
Referrer Name:
*
Referrer Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer Email
example@example.com
Referral Source Agency (write N/A if you were not an agency referral)
*
Referral Urgency
Please Select
Routine (Non emergent situation)
Referral By:
Self
Family Member
DSS
Agency Staff
School
Court System
Residential Program
Other
Potential Client’s Name
*
DOB:
*
-
Month
-
Day
Year
Date
Age
SS
*
(This information is only used for insurance verification purposes and is protected health information)
School Grade:
School Name:
Gender:
*
Male
Female
Legal Guardian’s Name(s): (If 18 or older please list yourself)
Relationship(s)to Client: (Ex: Parent, Self, etc.)
Client’s Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home/Work Phone #:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell #:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name(s):
Relationship(s)to Client:
Home/Work Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Cell #:
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Type of Insurance
*
Policy #
*
Requested Services:
Outpatient Therapy (Individual Counseling Sessions)
Intensive In-Home Services (For Individuals age 5-20 only)
Unsure/Would prefer to discuss
Appointment: Preferred Days of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Appointment: Preferred Times
Mornings
Afternoons
Evenings
Preferred Therapist (if available)
Female
Male
Preferred Therapist by Name (if available)
Reason for Referral:
(ie
Presenting Problem/Reason for Referral:
Signature of Person Completing Form
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: