Referral

The mission of Carolina Outreach is to provide best-practice, community-based mental health services that help individuals and families build upon their inherent strengths.

Information about person submitting this referral

Your name

* Your phone

Your email

Referring agency and/or relationship to client

Referral reasonBriefly describe why you are referring

If you are a human, ignore this field

Information about client being referred

* Site

Service requested

Primary insurance

Insurance

Type insurance here if it isn't in the menu above.

Insurance number

Secondary insurance

Leave blank if not applicable.

Secondary insurance

Type insurance here if it isn't in the menu above.

Secondary insurance no

Preferred language with agency

Current medications (if known)

Allergies

Current mental health diagnosis (if known)

Has client been at a hospital, emergency room, crisis center or utilized mobile crisis for mental health symptoms in the past year?

Is the client currently discharging from a hospital or PRTF?

Has client had any previous mental health and/or substance abuse treatment?

Please check any of the following options that apply to the client.

DSS or CPS involvement

Mental Health or SUD Court involvement

Legal/DJJ (probation, parole, pending charge, recent discharge from jail or prison)

Currently in the Transition To Community Living (TCL) program

Is client being referred from Healing Transitions shelter?

School-based Mental Health program

CommentsPlease add any other comments that would be helpful.

Referral

Information about person submitting this referral

Information about client being referred

Guardian

Additional guardian

Alternate contacts

Primary insurance

Secondary insurance