Online Referral Form Services Requested Types of Services Requested * Outpatient Therapy Wraparound/CRI Peer Support Support Groups School Based Mental Health (available onsite at specific schools) If you selected School-Based Mental Health, what school does your child attend? Referral Source (Person Completing the Form) * Referring Agency (if applicable) Referral Contact Email Referral Contact Phone Number (###) ### #### What is the best time to call the client? * Client Information Client Name * First Name Last Name Client Date of Birth * MM DD YYYY Client Gender * Client Race (optional) Phone Number * (###) ### #### May we contact / leave a message at this number? * Yes No Client's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Do you have health insurance? * Yes No If YES to health insurance, please list provider Preferred Language Parent or Legal Guardian's Information Complete only if referral is for client under the age of 18. Parent(s) or Legal Guardian(s) Relationship to Client Phone (###) ### #### Address (ONLY if different from client) Address 1 Address 2 City State/Province Zip/Postal Code Country Is the client currently receiving mental health or substance abuse services? * Yes No Primary Behavioral Health Diagnosis (if any and if known) Reason for Referral (symptoms, struggles, why seeking services) * Online Referral is NOT for crisis situations. * I acknowledge and understand that submission of a referral is not for crisis situations. If you are in crisis, please call 911. If you need assistance for a mental health crisis, please call Moses Cone Behavioral Health (24/7) at 336-832-9700 or Mobile Crisis at 877-626-1772. Thank you! Your referral form has been submitted. We will reach out and be in contact with you within two business days.
