CAROLINA THERAPEUTIC SERVICES FIRST CONSUMER REFERRAL FORM
Referring Date
-
Month
-
Day
Year
Date
Client Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is the consumer their own Guardian?
Yes
No
Client's Name Being Referred
Birthdate of Client Being Referred
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Living Arrangement: Home
Home
Other
Type of Insurance/Funding:
Wellcare
Carolina Complete
Alliance
Vaya
Partners
Homecare
Other
Please provide /fax legible copy of insurance card(s).
Insurance Number
Insurance Effective Date
-
Month
-
Day
Year
Date
Please share any pertinent information you would like for our office to know.
Referring Entity or Person's Name
Referring Entity or Person's Phone Number
Referring Entity or Person's Email Address
Behavioral Information
Rows
Yes
No
Self-Injury
Suicide Attempts
Sexually Aggressive
Legal problems
Property Destruction
Physical Aggression
Verbal Aggression
Hospitalization
Substance abuse
Criminal Activity
School Suspension
Are you in need of Home Health Care Services?
Submit
Should be Empty: