Refer for Support or Services Refer for Services or Support New Services Request(Required) General information, include details for referral Early intervention for young child with autism or other concern Special Education - Parent Education or Support Training for Support for EOR program Information or apply for My FIRST Key, Supported Living Support for your famiy member with disabilities from our Clinical Team Training or support for a self employment opportunity Other Please let us know what support you are looking for.Please describe the reason for the referral. Please include the member's current address, if different.(Required)Date(Required) MM slash DD slash YYYY Today's DateHave you talked to someone at FIRSTwnc about this referral?(Required) Yes No If so who? Individual/Child's Name(Required) First Last Individual's Phone(Required)Physical Address (Not a PO Box)(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What County does the person live in ?(Required) Individual's Email Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Other Race(Required)WhiteHispanic or LatinoBlack or African AmericanNative American or American IndianAsian or Pacific IslanderOtherLegally Responsible PersonSelfParent (Individual is under age 18)Guardian (same as parent)Guardian (other than parent)Who is the legally responsible party. If the person is over 18, there may be a parent and a guardian. FIRST needs information on both in this case.Legally Responsible Person's Name: (ie self, parent or guardian First Last Legally Responsible Person's Phone, if different from Individual (not agency staff or Care Manager_Legally Responsible Person's Email (Not Agency Staff or Care Manager) Parent Name: If different from legally responsible person First Last Parent Phone, if different from Legally Responsible Person (Not Agency staff or Care Manager)Parent Email, if different from Legally Responsible Person (Not Agency staff or Care Manager) Other Contact Person PhoneWhat is the best way to contact you?(Required) Phone Call Email Text Person or Agency Referring PhonePerson referring Email Community Program attending(Required) Please tell us what community program the person attends.School Attending(Required) Please tell us what school or childcare center the person attends.Receiving Services?(Required)InnovationsIEP at schoolMental Health ServicesWaitlist for InnovationsOtherWhat services is this person currently receiving? Select Option(Required) Please contact us to talk about ways FIRSTwnc can support my/our needs. Please contact my care manager 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 FIRSTwnc. CAPTCHA PDF Form to Fill and Mail