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Refer for Support or Services
Outpatient Therapy Referral
Outpatient Therapy Referral
New Services Request
Today's Date
*
MM slash DD slash YYYY
Today’s Date
Have you talked to someone at FIRSTwnc about this referral?
*
Yes
No
If so who?
Please describe the reason for the referral
*
Individual/Child’s Name:
*
First
Last
Date of Birth:
*
MM slash DD slash YYYY
Sex:
*
Male
Female
Other
Race:
*
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Other
Legal Guardian/Parent(s) Name:
*
First
Last
Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Legal Guardian/Parent(s) Email: (NOT QP)
*
Legal Guardian/Parent(s) Phone (NOT QP):
*
Caregiver: (if different from Parent or Guardian)
Caregiver Phone: (NOT QP)
Caregiver Email: (NOT QP)
How do you want us to contact you?
*
Phone Call
Email
Text
Person/Agency Referring:
Phone:
Email:
Community Program/School/Childcare Center
*
Please tell us what community program, school or childcare center the person attends
Receiving Services:
*
IEP at School
Innovations Waiver
Waitlist for waiver
Mental Health Services
Other
Primary Insurance – FIRSTwnc does not currently except Medicare
Secondary Insurance
Preferred Day for Appointment
Select All
Monday
Tuesday
Wednesday
Thursday
Friday
Other
Preferred Time of Day for appointments
Mornings from 9am to noon
Afternoons after 3pm
Open to anytime
Select Option
*
Please contact us to talk about ways FIRST can support my/our needs.
Please contact my care coordinator to discuss.
*
I understand that this consent is voluntary and is valid until the party withdraws this consent, in writing/verbally, at any time. I understand that there are statutes and regulations protecting the confidentiality of authorized information. I also understand that in order to receive appropriate treatment that information may be shared between treating agencies without consent in accordance with N.C.G.S 122 C-52 through 122 C-57.
*
I understand that this consent does not guarantee that these services will be provided by FIRST.
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