Professional Referral form for Mental Health Services

The information provided on this referral form is confidential and secure

Referral Source Information

Child/Adult Information

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.

Briefly describe the reason the person needs mental health services.