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About Us
Our Services
Resources
- Compliance and Ethics Line
Billing and Insurance
Locations

Referrals

Reach out Today

Please complete the referral form below if you are referring for a clinical assessment or if you are unsure of the clinical services that are needed.

If you are familiar with the services that we provide and want to refer for a specific service, please go to that service tab and complete the referral form on that page.

Referral Form

Comments

This field is for validation purposes and should be left unchanged.

Referring Person's Information

Name

First Last

Company

Email(Required)

Phone

Referral Information

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Male

Female

Other

Please select the service(s) you would like a referral for:

Intensive In Home

Day Treatment

Foster Care

Outpatient

Medication Management

Referred Individual's Address (PO Box or Street Address)(Required)

City(Required)

State(Required)

Zip Code(Required)

Phone(Required)

Referral Medicaid Number

Guardian Information

Is there a guardian?(Required)

Yes

Relationship:

Additional Information

Reason for Referral/Presenting Problems (currently active symptoms)

Number of hospitalizations in the past 2 years

Medications (if known)

Current MH Provider/Prescriber

Current Primary Care Provider

Referral Diagnisis

Schizophrenia

Schizoaffective

Bipolar d/o

MDD w/ psychosis

Other psychotic d/o

Diagnosis unknown

Please write in "other" diagnosis

Please select a preferred treatment location

Additional Support Documentation

Drop files here or

Accepted file types: jpg, png, pdf, docx, Max. file size: 256 MB, Max. files: 3.

Mooresville, NC

Phone: 704-660-6854
Fax: 704-662-0866

Concord, NC

Phone: 980-781-5156
Fax: 980-781-5346

Charlotte, NC

Phone: 980-237-9731
Fax: 980-237-9791

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