New Patient Referral Request
(Inbound/Incoming Referral)
Referral Date and Time
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Urgency of Referral
Emergent/Urgent (1st available appointment or follow-up within 24-48 hours)
Routine (1st available appointment or follow-up within 7 days)
Continuum Care Location:
*
Please Select
Charlotte,NC
Concord,NC
High Point,NC
Troy,NC
Winston-Salem,NC
To which office is the individual requesting to be referred?
REFERRAL INFORMATION
Name of Person Initiating the Referral
Name of Agency, if applicable
Phone Number of Person Initiating the Referral
Email Address for referral follow-up
How did you hear about Continuum Care Services, Inc.?
If you were referred by a specific person, please include their name so that we can thank them!
PATIENT INFORMATION
Name of person being referred
Preferred Name or "Nickname"
Date of Birth
Age at time of referral
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Evaluation Requested for the following service(s)
Child/Adolescent Mental Health
Child/Adolescent Substance Use
Adult Mental Health
Adult Substance Use
Comprehensive Clinical Assessment ONLY
Outpatient Therapy
Medication Management (*available in select locations)
Insurance Information
Self-Pay/Uninsured
Private/Commercial Insurance (e.g. BCBS)
Medicaid
NC HealthChoice
Medicare
Medicaid PHP - Wellcare of North Carolina
Medicaid PHP - AmeriHealth Caritas of North Carolina
Medicaid PHP - Carolina Complete Health
Medicaid PHP - Healthy Blue of North Carolina
Medicaid PHP - United Healthcare Community Plan
Ambetter
Other
LEGALLY RESPONSIBLE PERSON CONTACT INFORMATION
Name of Parent/Guardian/Legally Responsible Person (if other than "self")
Primary Phone Number
Secondary Phone Number
REASON FOR REFERRAL
Please provide specific information of precipitating events that led to this referral.
The person for whom you are making this referral is aware of the referral.
*
Yes
No
The person for whom you are making this referral is willing to participate in an assessment and treatment recommendations.
Yes
No
Unsure, seeking additional information.
Are there any potential staff safety risks? Select all that apply.
Neighborhood safety risks
History of suicidal thoughts/attempts
History of homicidal thoughts/attempts
Aggressive animals/pets
Frequent psychotic episodes
Hostility toward a particular race or sex
None
Does the patient have a Primary Care Provider?
Yes
No
Name of Primary Care Physician
Name and Address of Practice
Physician's Office Phone Number:
Physician's Office After-hours Phone Number:
Submit
Should be Empty: