Online Referral Form Referral Source (Person Completing the Form) * Referring Agency (if applicable) Referral Contact Email Referral Contact Phone Number (###) ### #### What is the best time to call the client? * Client Information Client Name * First Name Last Name Client Date of Birth * MM DD YYYY Client Gender * Client Race (optional) Phone Number * (###) ### #### May we contact / leave a message at this number? * Yes No Client's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Do you have health insurance? * Yes No If YES to health insurance, please list provider and ID# Preferred Language Parent or Legal Guardian's Information Complete only if referral is for client under the age of 18. Parent(s) or Legal Guardian(s) Relationship to Client Phone (###) ### #### Address (ONLY if different from client) Address 1 Address 2 City State/Province Zip/Postal Code Country Services Requested Types of Services Requested * Outpatient Therapy Couples/Family Therapy Patient Navigation/Advocacy Peer Support Groups Is the client currently receiving mental health or substance abuse services? * Yes No Primary Behavioral Health Diagnosis (if any and if known) Reason for Referral (symptoms, struggles, why seeking services) * Online Referral is NOT for crisis situations. * I acknowledge and understand that submission of a referral is not for crisis situations. If you are in crisis, please call 911. If you need assistance for a mental health crisis, please call Moses Cone Behavioral Health (24/7) at 336-832-9700 or Mobile Crisis at 877-626-1772. Thank you! Your referral form has been submitted. We will reach out and be in contact with you within two business days.