(retired form) PROFESSIONAL REFERRAL FORM FOR MENTAL HEALTH SERVICES 1

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

Client's First Name

Client's Last Name

Client's Birthday

Please Explain

Client's Gender

Male
Female
Other

Please Explain

Is the Client 18 years or older?

Name of School

What Grade in School?

Client's Parent/Legal Guardian Marital Status

Single
Married
Separated
Divorced
Widowed
Remarried
Partnered

Client's Marital Status

Single
Married
Divorced
Separated
Widowed
Remarried
Partnered

Does the client have accessiblity needs that we need to be aware of or make accommodations for?

If yes, please explain the client's specific accessibility needs so that we may accomodate.

Preferred Service Location

Choose all locations you are willing and capable to travel to

Greensboro Location
Archdale/High Point Location
Elon Office
Telehealth

CLIENT CONTACT INFORMATION

Is the client in foster care or DSS custody?

What County?

Social Worker's Name

Social Worker's Contact Number

Social Worker's Contact Email

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.

Parent/Legal Guardian/Foster Parent Name

Parent/Legal Guardian/ Foster Parent Name

Address of Residence for the Client

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Relationship to Client?

Best Email for Contacting Client or Client's Parent/Guardian

Cell Number

Home Number

Work Number

Does the client have another parent/legal guardian residing within the home?

Yes
No
Unsure

Does the client have another parent/legal guardian living outside of the home presently acting as a parent/legal guardian in the client's life and with active parental rights to the client?

Yes
No
Unsure

2nd Parent/Legal Guardian Full Name

2nd Parent/Legal Guardian Best Contact Number

2nd Parent/Legal Guardian Email

2nd Parent/Legal Guardian's Relationship to the Client

2nd Parent/Legal Guardian's Mailing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

CLIENT INSURANCE/PAYMENT INFORMATION

Family Solutions is In-Network with Blue Cross Blue Shield, United Health Care/UMR, and accepts Medicaid (Cardinal Innovations, Sandhills, Healthy Blue, United, AmeriHealth, Wellcare, or Carolina Complete), & NC Healthchoice

Type of Insurance

Medicaid
NC Healthchoice
Blue Cross Blue Shield
United Health Care/UMR
Self-Pay
Out of Network (UHC, Cigna, Aetna, etc)

Does the client have a secondary insurance policy??

Yes, the client has another insurance policy
No, the client only has the primary insurance listed

Which type of Medicaid do you have?

Healthy Blue
United
AmeriHealth
Wellcare
Carolina Complete
Sandhills
Vaya

Private Insurance Name

Insurance ID #

Secondary Insurance Name

Secondary Insurance ID #

REFERRAL SOURCE INFORMATION

Complete this section so we can contact you after the referral has been made.

Name of Referring Professional

Agency/Organization/Office Name

Referral Source Phone Number

Referral Source Fax Number

Referral Source Email

Has the Client or the Caretaker been informed of the referral?

CHILD/ADULT MENTAL HEALTH INFORMATION

Current Medication

Current DSM V Diagnosis

Diagnosing Professional's Name & Phone

REASON FOR TREATMENT: In your own words, briefly describe the reason the client is in need for mental health services.

DESIRED TREATMENT OUTCOMES: In your own words, describe the results you want for the client from receiving mental health services.

Please indicate below if this is a request for our MATCH Program or our DBT Program. These two specialized services require additional screening and assessment to determine if you are a good fit. Someone from our team will contact you to request additional information.

Specialized Program Request. See links above for more information about MATCH and DBT.

MATCH Program
DBT Program

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.)

Any additional relevant medical information staff should know about the client (IE: Allergies, Medical Conditions)

Clients Weekly Preferred Availability - Our office hours are: Mon-Fri, 8am to 5pm with limited afterhours appointments.

Please check the days that work best for you

Monday
Tuesday
Wednesday
Thursday
Friday
Inconsistent Schedule

Please explain if client does not have a consistent schedule.

How did you hear about us?

Choose all that apply.

Have made referral in past
Google Search
Facebook
Other

Use this to upload additional documentation you want to send with referral.

Browse (no files uploaded)

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.

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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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