Referrals

Make a Referral
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
Referral Patient's Address

Street Address

Street Address Line 2

City State

Zip Code
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 *
Have documentation you would like to send with this referral?

Yes No
Please attach it below by clicking the "Browse Files" button.

Browse Files

Cancel of
Does the patient have health insurance?

Yes No Maybe/Unknown
Insurance Information
This information can help us get the patient an appointment sooner.
Insurance Carrier: Policy Number:
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