Professional Referral form for Mental Health ServicesThe information provided on this referral form is confidential and secureReferral Source Information Name * First Name Last Name How did you hear about us? * Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Fax (###) ### #### Email * Has the client or guardian been informed of the referral? Yes No Child/Adult Information Child's Name First Name Last Name Birthday MM DD YYYY Age Race Address Address 1 Address 2 City State/Province Zip/Postal Code Country Child/Guardian's Phone (###) ### #### Child/Guardian's Email Gender Male Female Other Marital Status Single Married Divorced Separated Name of School What Grade Level in School Current medications Current DSM V Diagnosis Insurance Payment Information Wrights Care Services is in network with Aetna, Blue Cross Blue Shield, Cigna, Magellan, Medcost, United Healthcare, and accepts Medicaid/NC Healthchoice (Sandhills). Our rates for services are $150 for the intake appointment and $120 for each following appointment. Type of Insurance Private Medicad NC Healthchoice Self Pay Reason for Referral Please let us know when is the best time to contact you. Thank you!
