PROFESSIONAL REFERRAL FORM FOR MENTAL HEALTH SERVICES

This referral form is meant to be used by medical and mental health providers and other agencies, organizations and professionals seeking to initiate outpatient services for clients in their care.  If you have any additional documentations you wish to share concerning a referred client, please attach to this form or fax directly to Family Solutions at 336-899-8811.  If you wish to fax a referral form, please use our faxable referral form format available as a PDF at the bottom of our Referral Forms page.  
All information submitted on this referral form is completely confidential, secure and encrypted. After you submit the referral form, you will be emailed a copy for you records. 
CLIENT INFORMATION

CONTACT INFORMATION
If the client is in DSS custody or foster care, please use this section below to inform us of the current foster family's contact information so that we may contact the foster family to coordinate appointments.  
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INSURANCE/PAYMENT INFORMATION
Family Solutions is In-Network with Blue Cross Blue Shield and accept Medicaid (Cardinal Innovations, Sandhills), NC Healthchoice
REFERRAL SOURCE INFORMATION
Complete this section so we can contact you after the referral has been made. 
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CHILD/ADULT MENTAL HEALTH INFORMATION
DESIRED TREATMENT OUTCOMES: In your own words, describe the results you want for the child/adult/self from receiving mental health services.
Any additional information or request you'd like to provide us (Examples: Therapist preferences, former client with our agency, Siblings in attendance with Agency, Type of Therapy, language preferences)
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PLEASE NOTE: An excuse form will be provided for all appointments that may impact the client's work or school schedule/commitments.  After you hit submit below, a copy of the form will be emailed to you for you records. 

Thank you for contacting us!

We have received your referral information and our intake staff will contact you shortly. 

If you have not heard from us within two business days, please call us so we can stay on top of it. 

Family Solutions’ Intake Staff

231 N Spring St

Greensboro, NC 27401

336-899-8800 ext 10 

intake@famsolutions.org

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