REFERRAL FORM

EMPOWERMENT QUALITY CARE SERVICES

   Referral Coordinator: Lisa Campbell

                                                                 Office: 704-717-7477 Fax: 704-717-7457

8535 Cliff Cameron Drive Suite 100, Charlotte, NC 28269

                                                                      Email: admin@eqcscharlotte.com Web: www.eqcscharlotte.com
REFERRAL FORM
Date of Referral:

Month Day Year
Date
Contact Person:
Contact Person Phone Number:
Please enter a valid phone number.
ReferralSource:

Self Family Member DSS Agency Staff MCO: School Court System Residential Program Other
Potential Consumer’sName
DOB:

Month Day Year
Date
Gender:

Male Female
Legal GuardiansName(s):
Relationship(s)to Consumer:
Home Phone #:
Please enter a valid phone number.
Cell Phone #:
Please enter a valid phone number.
Email
example@example.com
Consumer’s Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Type of Insurance:
Policy #:
Requested Services

Psychosocial Rehabilitation (PSR) Substance Abuse Intensive Outpatient (SAIOP) Peer Support Community Support Team (CST) Intensive In home (IIH) Out Patient Therapy (OPT)
Reason for Referral:
Should be Empty:

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