Outpatient Therapy Referral New Services Request Today's Date* MM slash DD slash YYYY Today's Date Have you talked to someone at FIRST about this referral?* Yes No If so who? Individual/Child’s Name:* First Last Date of Birth:* MM slash DD slash YYYY Sex:* Male Female Other Race:*WhiteHispanic or LatinoBlack or African AmericanNative American or American IndianAsian / Pacific IslanderOtherLegal Guardian/Parent(s) Name:* First Last Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal Guardian/Parent(s) Email: (NOT QP)* Legal Guardian/Parent(s) Phone (NOT QP):*Caregiver: (if different from Parent or Guardian) Caregiver Phone: (NOT QP)Caregiver Email: (NOT QP) How do you want us to contact you?* Phone Call Email Text Person/Agency Referring: Phone:Email: Community Program/School/Childcare Center* Please tell us what community program, school or childcare center the person attendsReceiving Services:*IEP at SchoolInnovations WaiverWaitlist for waiverMental Health ServicesOtherPlease describe the reason for the referral*Primary Insurance - FIRST does not currently except Medicare Secondary Insurance Preferred Day for Appointment Select All Monday Tuesday Wednesday Thursday Friday Other Preferred Time of Day for appointments Mornings from 9am to noon Afternoons after 3pm Evenings from 5pm to 7pm Open to anytime Select Option* Please contact us to talk about ways FIRST can support my/our needs. Please contact my care coordinator to discuss. * I understand that this consent is voluntary and is valid until the party withdraws this consent, in writing/verbally, at any time. I understand that there are statutes and regulations protecting the confidentiality of authorized information. I also understand that in order to receive appropriate treatment that information may be shared between treating agencies without consent in accordance with N.C.G.S 122 C-52 through 122 C-57. * I understand that this consent does not guarantee that these services will be provided by FIRST.