REFERRAL FORM

EMPOWERMENT QUALITY CARE SERVICES

   Referral Coordinator: Shavon Joseph

                                                                 Office: 704-717-7477 Fax: 980-301-8287

8535 Cliff Cameron Drive Suite 100, Charlotte, NC 28269

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

MonthDayYear
Date
Referral Source Name:
Referral Source Contact Number:
Please enter a valid phone number.
Referral Source Email Address:
Please enter a valid phone number.
Referral Source Email Address:
example@example.com
Referral Source:

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

MonthDayYear
Date
Identified Gender:

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Insurance:
Policy #:
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:
Should be Empty: