PERSONAL REFERRAL FORM FOR MENTAL HEALTH SERVICES

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
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INSURANCE/PAYMENT INFORMATION
Family Solutions is In-Network with Blue Cross Blue Shield and accept Medicaid (Cardinal Innovations, Sandhills) and NC Healthchoice.  We also accept out-of-network insurances and self-pay clients.  Our rates for services are $120 for the intake appointment and $100 for each following appointment.
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PRIMARY CARE PHYSICIAN 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 child/adult/self from receiving mental health services.
Any additional information or request you'd like to provide us (IE: Therapist preferences, former Client with Agency, Siblings in attendance with Agency, Type of Therapy)
PLEASE NOTE: An excuse form will be provided for all appointments that may impact the client's work or school schedule/commitments.

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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