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
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CLIENT 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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CLIENT 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. 

CHILD/ADULT MENTAL HEALTH INFORMATION
DESIRED TREATMENT OUTCOMES: In your own words, describe the results you want for the client from receiving mental health services.
Any additional information or requests you'd like to provide us (Examples: therapist preferences, former client history with our agency, siblings in attendance with agency, type of therapeutic approach requested, language preferences etc.)
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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!

Thank you for your interest in Family Solutions.  We have received your referral submission and our intake staff will be in contact with the referred client shortly. 

Our intake team's goal is to respond to all referrals submitted within 2 business days.  If the client has not heard from one of our intake staff members within that time, please call us at 336-899-8800.  We want to make sure to handle your request as soon as possible.  

Family Solutions’ Intake Team

Ph: 336-899-8800

F: 336-899-8811

231 North Spring Street

Greensboro, NC 27401

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