Referral Form Referring Party InformationReferring Organization Type*DSSMCOJuvenile JusticePrivate PartyPrimary Care PhysicianReferring DSS*Select County DSSAlleghany CountyAlexander CountyAlleghany CountyAnson CountyAshe CountyAvery CountyBeaufort CountyBertie CountyBladen CountyBrunswick CountyBuncombe CountyBurke CountyCabarrus CountyCaldwell CountyCamden CountyCartere CountyCaswell CountyCatawba CountyChatham CountyCherokee CountyChowan CountyClay CountyCleveland CountyColumbus CountyCraven CountyCumberland CountyCurrituck CountyDare CountyDavidson CountyDavie CountyDuplin CountyDurham CountyEdgecombe CountyForsyth CountyFranklin CountyGaston CountyGates CountyGraham CountyGranville CountyGreene CountyGuilford CountyHalifax CountyHarnett CountyHaywood CountyHenderson CountyHertford CountyHoke CountyHyde CountyIredell CountyJackson CountyJohnston CountyJones CountyLee CountyLenoir CountyLincoln CountyMacon CountyMadison CountyMartin CountyMcDowell CountyMecklenburg CountyMitchell CountyMontgomery CountyMoore CountyNash CountyNew Hanover CountyNorthampton CountyOnslow CountyOrange CountyPamlico CountyPasquotank CountyPende CountyPerquimans CountyPerson CountyPitt CountyPolk CountyRandolph CountyRichmond CountyRobeson CountyRockingham CountyRowan CountyRutherford CountySampson CountyScotland CountyStanly CountyStokes CountySurry CountySwain CountyTransylvania CountyTyrrell CountyUnion CountyVance CountyWake CountyWarren CountyWashington CountyWatauga CountyWayne CountyWilkes CountyWilson CountyYadkin CountyYancey CountyReferring MCO*Select MCO OrganizationAlliance Behavioral HealthcareCardinal Innovations Healthcare SolutionsCenterpoint Human ServicesEastpointePartners Behavioral Health ManagementSandhills CenterSmoky Mountian CenterTrillium Health ResourcesReferring Juvenile Justice Entity*Select Juvenile Justice Entity23rd District24th District25 District30th DistrictDistrict - Other**Alexander CountyAlleghany CountyAshe CountyBuncombe CountyGuilford CountyIredell CountyMecklenburg CountyWilkes CountyDistrict - Other** (please list in box below)Referral Contact Name* First Last Contact Phone Number*Contact Email* Insurance Type*Medicaid ID/Insurance NumberPreferred Service Location*Select Preferred Service LocationNo PreferenceAlleghany CountyAlexander CountyAlleghany CountyAnson CountyAshe CountyAvery CountyBeaufort CountyBertie CountyBladen CountyBrunswick CountyBuncombe CountyBurke CountyCabarrus CountyCaldwell CountyCamden CountyCartere CountyCaswell CountyCatawba CountyChatham CountyCherokee CountyChowan CountyClay CountyCleveland CountyColumbus CountyCraven CountyCumberland CountyCurrituck CountyDare CountyDavidson CountyDavie CountyDuplin CountyDurham CountyEdgecombe CountyForsyth CountyFranklin CountyGaston CountyGates CountyGraham CountyGranville CountyGreene CountyGuilford CountyHalifax CountyHarnett CountyHaywood CountyHenderson CountyHertford CountyHoke CountyHyde CountyIredell CountyJackson CountyJohnston CountyJones CountyLee CountyLenoir CountyLincoln CountyMacon CountyMadison CountyMartin CountyMcDowell CountyMecklenburg CountyMitchell CountyMontgomery CountyMoore CountyNash CountyNew Hanover CountyNorthampton CountyOnslow CountyOrange CountyPamlico CountyPasquotank CountyPende CountyPerquimans CountyPerson CountyPitt CountyPolk CountyRandolph CountyRichmond CountyRobeson CountyRockingham CountyRowan CountyRutherford CountySampson CountyScotland CountyStanly CountyStokes CountySurry CountySwain CountyTransylvania CountyTyrrell CountyUnion CountyVance CountyWake CountyWarren CountyWashington CountyWatauga CountyWayne CountyWilkes CountyWilson CountyYadkin CountyYancey CountyType of Service Requested*Adoption/Post AdoptionFoster Care- FFCFoster Care- TFCFoster Care- IAFTResidential- PRTFResidential- Level IIIResidential- Level IIResidential- DSSEducational- Therapeutic Day TreatmentIn Home- IIHOutpatient Therapeutic ServicesClient and Placement InformationLegal Guardian Name* First Last Client Name* First Middle Last Gender*FemaleMaleDate of Birth Date Format: MM slash DD slash YYYY Placed With Other Children*YesNoUnknownReason No Other Children in HomeChild Requires Placement with Slibling Group*YesNoNumber Of Additional SiblingsSlibling 1 First Middle Last Slibling 2 First Middle Last Slibling 3 First Middle Last Specific School District Desired*YesNoUnknownPreferred School Disctrict*Diagnosis (List) Medications (List) Disability Information*Physical DisabilityMedical ComplicationBothNoneUnknownPhysical Disabilities or Medical Complications*Agressive Towards Others*YesNoUnknownSelf Harming Behaviors*YesNoUnknownJuvenile Justice Invloved*YesNoUnknownSubstance Abuse*YesNoUnknownFire Setting Risk*YesNoUnknownRunning Risk*YesNoUnknownSuicide Attempts Within Past Year*YesNoUnknownNumber of Suicide AttemptsHospitalizations Within Past Year*YesNoUnknownNumber of HospitalizationsSexual Abuse*Victim of AbusePerpetratorBoth Victim and PerpetratorNoUnknownPhysical Abuse*Victim of AbusePerpetratorBoth Victim and PerpetratorNoUnknownAdditional InformationDocumentation Upload Drop files here or (upload supporting documentation)CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. Take A Tour Interactive Map Newsletter
