Referrals

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Referring Provider's Name *
Referring Provider Phone Number *
Best Time to Call You (If Needed)
Patient Information

Tell us about the patient you would like to refer.
Referral Patient's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Referral Patient's Phone Number *
What service(s) does the patient need? (Select all that apply) *

Medication Therapy Medication and Therapy Addiction Treatment Psychological Testing Unsure
Reason for appointment *
Does the patient have health insurance?

Yes No Maybe/Unknown
We're Sorry

We are unable to recommend a certain clinician or agency at this time. You may find helpful information, including free or discounted behavioral healthcare service options, by visiting the following website: https://www.nc211.org/resources-uninsured.
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Make a Referral