REFERRAL FORM

EMPOWERMENT QUALITY CARE SERVICES

8535 Cliff Cameron Drive Suite 100 Charlotte, NC 28269

Intake Specialist: Trivina Brown

                                                                 Office: 704-717-7477

Fax: 980-301-8287

                                                                      Email: trivina@eqcscharlotte.com

Web: www.eqcscharlotte.com
REFERRAL FORM
Date of Referral:

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SelfFamily MemberDSSAgency StaffMCO:SchoolCourt SystemResidential ProgramOther
Potential Member's Name
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Member Address:

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Requested Services

Psychosocial Rehabilitation (PSR)Substance Abuse Intensive Outpatient (SAIOP)Peer SupportCommunity Support Team (CST)Intensive In home (IIH)Out Patient Therapy (OPT)
Reason for Referral:
EQCS can provide services to address individual needs: YES NO

Referrals/Recommendations:
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